WE B866p 1834- UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D. C. OPO 16—67244-1 798005 / PATHOLOGICAL AND SURGICAL OBSERVATIONS DISEASES OF THE JOINTS. --7— By B. C. PRODIE, V.P.R.S. SERJEANT-SURGEON TO THE KING, AND SURGEON TO ST. GEORGE'S HOSPITAL. THIRD EDITION, WITH ALTERATIONS AND ADDITIONS. WASHINGTON: STEREOTYPED AND PUBLISHED BY DUFF GREEN. 1834. WE B8£6p 1834^ ADVERTISEMENT, This new edition of my Treatise on the Diseases of the Joints is not a mere republication of those which have preceded it. There are not more than two chapters which appear exactly in their former shape; and some of them are so altered, or have received such extensive additions, that they bear little resemblance to their originals. It has been my wish to add, to the materials which I had formerly collected, whatever information respect- . ing these diseases I have since been able to acquire. But to accomplish this object has been a work of no small labor to one, whose time is occu- pied by a -variety of other engagements : and I trust that what I have now mentioned will be deemed a sufficient apology for the circumstance of this volume having been announced to the public so long before it has actually appeared. B. C. Brodie. Saville Row, March 28, 1834. CONTENTS. Page Introduction ----... i CHAP. I. ON INFLAMMATION OF THE SYNOVIAL MEMBRANES OF JOINTS. Sect. I.—Pathological Observations - - - - 3 Sect. II.—On the Causes and Symptoms of this Disease - 7 Sect. III.—On the Treatment - - - - 11 Sect. IV.—Cases - - ----- 16 CHAP. II. ON ULCERATION OF THE SYNOVIAL MEMBRANE - - - 25 CHAP. III. ON CASES, IN WHICH THE SYNOVIAL MEMBRANE HAS UNDERCONE A MORBID CHANGE OF STRUCTURE. Sect. I.—Pathological Observations - - - - 26 Sect. II.—On the Symptoms of this Disease - -r>' 32 Sect. III.—On the Treatment - - - - 33 CHAP. IV. ON THE ULCERATION OF THE ARTICULAR CARTILAGES. Sect. I.—Pathological Observations - - - 35 v VI CONTENTS. PAGE Sect. II.—On the Symptoms of this Disease - / - 47 Sect. III.—On the Treatment - - - - - 53 Sect. IV.—Cases - r - - - - 62 CHAP. V. ON A SCROFULOUS DISEASE OF THE JOINTS, HAVING ITS ORIGIN IN THE CAN- CELLOUS STRUCTURE OF THE BONES. Sect. I.—Pathological Observations - - - - 69 Sect. II.—On the Symptoms of this Disease - - - 74 Sect. III.—On the Treatment - - - - -77 Sect. IV.-.Case? - ..... 81 CHAP. VI, ON CARIES OF THE SPINE. Sect. I.—Pathological Observations - - - - 87 Sect. II.—On the Symptoms of Caries of the Spine - - 93 Sect. III.—On the Treatment ----- 99 CHAP. VII. ON TUMORS AND LOOSE CARTILAGES IN THE CAVITIES OF THE JOINTS 103 CHAP. VIII. ON MALIGNANT DISEASES OF THE JOINTS <- * - 107 CHAP. IX. ON SOME OTHER DISEASES OF THE JOINTS - - .- \\\ CHAP. X. ON INFLAMMATION OF THE BURSJ5 MUCOS/E. Sect. I.—History and Symptoms of this Disease - - 121 CONTENTS. vii PAGE Sect. II.—On the Treatment - - 123 Sect. III.—Cases - - - - - 124 ADDITIONAL NOTES. 1. On Ulceration of the Articular Cartilages - ■< 126 2. On the Absorption of Cartilages complicated with the Effects of Friction on the Bones - 131 INTRODUCTION. The following pages contain a series of observations, which Were begun several years ago, and which have been continued, not without considerable labor, up to the present period. They relate to a class of diseases which have strong claims on the attention of the surgeon; since they are of very frequent occurrence; are a source of serious anxiety to the patients; and, for the most part, if neglected, proceed to an unfavorable termination. There are other circumstances, also, which seemed to render the morbid affections of the joints a fit subject of investigation. They have scarcely met with the attention which they merit from former pathologists. The terms, white swellings, scrophulous, joints, &c, have been used without any well-defined meaning, and almost indiscriminately; so that the same name has been fre- quently applied to different diseases, and the same disease has been distin- guished by different appellations. Confusion with respect to diagnosis al- ways gives rise to a corresponding confusion with respect to the employment of remedies; and hence I was induced to hope, that, if it were possible to improve our pathological knowledge of the diseases to which I have alluded, this might lead, not indeed to the discovery of new methods of treatment, but to a more judicious and scientific application of those which are already known, and a consequent improvement of chirurgical practice. The joints, like the other animal organs, are not of a simple and uniform, but of a various and complicated structure. Although, in the advanced stages, the diseases, to which they are liable, extend to all the dissimilar parts of which they are composed, it is to be presumed that such is not the case in the beginning. We cannot doubt that here, as elsewhere, the morbid actions commence sometimes in one and sometimes in another texture; and that they differ in their nature, and are variously modified, and, of course, require to be differently treated, according to the mechanical organization, and the vital properties of the part, in which they originate. It was under the influence of these impressions that I endeavored to pur- sue my inquiries into the subject of the present treatise. Believing that nothing has contributed in a greater degree towards the modern improve- ments in surgery, than the practice of investigating by dissection the changes of anatomical structure, which disease produces, I availed myself of every opportunity which occurred of making such examinations. In particular, 1 was anxious to do this where the morbid changes were still in an early stage, and where I had the opportunity of noting the symptoms by which the inci- pient disease was indicated; and the knowledge which was thus acquired became the basis of my future observations. In laying the results before the 1 2 INTRODUCTION. public, I cannot be otherwise than conscious, that these researches are still imperfect. But I feel assured, at the same time, that those who are engaged in the study of pathology, will make due allowance for the difficulties which belong to this most complicated of all the sciences, and will not be disposed to criticise my labors severely, because they find that there is still an ample space left for those who may be willing to engage in similar inquiries. Some of my readers will recognise in the present work the substance of three papers, which have been published in the fourth and two subsequent volumes in the Medico-Chirurgical Transactions; but they will also find a considerable proportion of new matter. I have met with no reasons for altering my former arrangement of those affections of the joints which are of most frequent occurrence. Indeed, it has been to me a source of much satisfaction, that all my subsequent observations, founded on numerous addi- tional cases and dissections, have tended to confirm the accuracy of those pathological views which I was led to adopt several years ago, and which I ventured to bring forward in the first of those papers to which I have al- luded. CHAPTER I. ON INFLAMMATION OF THE SYNOVIAL MEMBRANES OF JOINTS. SECTION I. Pathological Observations. The soft parts, which, added to the bones and cartilages, constitute the structure of the joints, are, the synovial membranes, by which the lubrica- ting fluid is secreted; the ligaments, by which the bones are connected to each other; and the fatty substance, which occupies what in certain posi- tions would otherwise be empty spaces. It is to be supposed, that the adi- pose membrane belonging to the joints may be inflamed; that it may be the seat of abscesses and tumors, as well as that which is situated beneath the skin or in the interstices of the muscles; and the ligaments cannot be regarded as more exempt from disease than the fibrous membranes, which they very nearly resemble in their texture. It is not improbable that some of the pains which take place in the joints in syphilitic affections, may depend on a diseased action occurring in the ligaments; and there can be no doubt that the long continued symptoms, which occasionally follow a severe sprain, depend on these same parts being in a state of slow inflammation, in conse- quence of some of their fibres having been ruptured, or over-stretched. I cannot say that I have never seen a case where disease, independently of these causes, has originated in the ligaments; but I certainly have never met with a case where it has been proved to have done so by dissection; and it may be safefy asserted, that this is a rare occurrence, and not what hap- pens in the ordinary diseases to which the joints are liable. On the other hand, no part of the body is much more frequently diseased than the synovial membranes. This is what their anatomical structure and functions might lead us to expect, since we find that living organs are more subject to have their natural functions deranged, in proportion as they are more vascular, and as they are employed in a greater degree in the process of secretion. The synovial membranes of the joints have not been well described by the majority of the old, nor even of modern, anatomists. A sufficiently accurate account of them, however, has been published by Dr. W. Hun- ter, in a communication to the Royal Society on the structure of cartilage published in the forty-second volume of the Philosophical Transactions, and since then by M. Bichat, in his Traite dts Membranes; and to these authors I may refer those of my readers who wish to see their anatomy more fully explained. At present, it is sufficient for me to observe, that the office of the synovial membrane of a joint is to secrete the synovia, by which the joint is lubricated; that it lines the ligaments, by which the bones are held 4 OBSERVATIONS ON THE together; covers the bones themselves for a small extent, taking the place of the periosteum ; and that from thence it passes over the cartilaginous surfaces, and the inter-articular fat. Where it adheres to the bones and soft parts, it very much resembles the peritonaeum in its structure, and possesses consid- erable vascularity; but where it is reflected over the cartilages it is thin, and readily torn : its existence, however, even here, may be always distinctly demonstrated by a careful dissection. The synovial membrane of a joint forms a bag, having no external opening; in this respect resembling the peritoneum, the pleura, and the pericardium; which it also resembles in its functions, and to which it bears some analogy in its diseases. Cases occasionally (but not often) occur, in which a joint is swollen from a preternatural quantity of fluid collected in its cavity, without pain or in- flammation. This may be supposed to arise, either from a diminished action of the absorbents, or an increased action of the secreting vessels. The dis- ease may be compared to the dropsy of the peritonaeum or pleura; or, more properly, to the hydrocele; and it has been not improperly designated by the terms " Hydarthms," and " Hydrops articuli." It more frequently happens that there is swelling from fluid in a joint, with inflammation and pain. Here we may presume that the disease con- sists in an inflammation of the synovial membrane, with a consequent in- crease of the secretion from its surface ; and I have found this confirmed by the appearances observed in many such cases, in which I had the oppor- tunity of examining the affected parts after death. In some instances, while there is still pain and inflammation in the joint, the fluid is felt indistinctly, as if a considerable mass of soft substance lay over it. Often, when the inflammation has subsided, and the fluid is no longer to be felt, the joint remains swollen and stiff; painful, when bent or extended beyond a certain point, and liable to a return of inflammation from slight causes. The appearances observed on dissection, in the following cases, seem to throw light on this subject. Case I.—A middle-aged man was admitted into St. George's Hospital, in September, 1810, on account of a disease in one knee. The joint was swol- len and painful, with a slight stiffness, and with fluid in its cavity. The swelling extended some way up the anterior part of the thigh, behind the lower portion of the extensor muscles. It subsided under the use of blis- ters and liniments. Two months after his admission into the hospital, he was seized with a fever, apparently unconnected with the disease in the knee, of which he died. On examining the affected joint, the synovial membrane was found more capacious than natural, so that it extended up the anterior surface of the femur at least an inch and a half higher than under ordinary circumstances. Throughout the whole of its internal surface, ex- cept where it covered the cartilages, the membrane was of a dark red coloj-; the vessels being as numerous, and as much distended with blood, as those of the tunica conjunctiva of the eye in a violent ophthalmia. At the upper and anterior part of the joint, a thin flake of coagulated lymph was effused from the inner surface of the synovial membrane, of the size of a half-crown piece. There was no other appearance of disease, except that at the edge of one of the condyles of the femur, the cartilage adhered to the bone less firmly than usual. Case II.—A. B., a young man, in the spring of the year 1808, in conse- quence (as he supposed) of exposure to damp and cold, became affected with a painful swelling of one of his knees. Under the treatment employed by the practitioner whom he consulted, the pain and swelling in great measure, DISEASES OF THE JOINTS. 5 but not entirely, subsided. Three months after the disease first took place, he was admitted into St. George's Hospital. At this time the knee was swollen, painful, and tender. The swelling had the form of the articulating ends of the bones. The leg was confined to nearly the straight position, and admitted of very little motion on the thigh. His general health was unaffected. Blood was taken from the knee by cupping ; and afterwards it was rubbed daily with mercurial ointment and camphor. The pain and inflammation subsided ; and the swelling and stiffness were in some measure lessened. It afterwards became necessary to amputate the limb on account of another disease. The operation was performed on the 15th of December, 1808, and I did not neglect the opportunity of examining the joint. The bones, cartilages, and ligaments, were in a natural state. The synovial membrane was increased in thickness to about one-eighth of an inch, and was of gristly texture. It was closely attached to the surrounding cellular membrane and fascia by means of coagulated lymph, which had been formerly effused on its external surface. Case III.—A middle-aged man, who labored under an organic disease of the liver, was admitted into St. George's Hospital on the 19th of December, 1821, on account of a painful swelling of one knee. Blood was taken from the knee by cupping, and afterwards blisters were applied. The affection of the knee was much relieved under this treatment, but the joint remained rather larger than natural, and somewhat stiff. The disease in the liver con- tinued to make progress, and the man died on the 11th February, 1822. On examining the body after death, the synovial membrane of the knee was found slightly thickened, and of a grissly structure. The vessels on its inner surface were more loaded with blood than under ordinary circum- stances. The cartilage covering that portion of the articulating extremity of the femur which corresponds to the petella, in one spot of about three quarters of an inch in diameter, presented an irregular surface, as if it had been partially absorbed, but not to a sufficient extent to expose the surface of the bone below. These cases seem to explain the usual consequences of inflammation of the synovial membrane. It occasions, 1st, a preternatural secretion of synovia ; 2dly, effusion of coagulated lymph into the cavity of the joint; 3dly, in other cases, a thickening of the membrane ; a conversion of it into a gristly sub- stance ; and an effusion of coagulated lymph, and probably of serum, into the cellular texture, by which it is connected to the external parts. I have seen several cases where, from the appearance of the joint, and other circumstances, there was every reason to believe that the inflammation had produced adhesions, more or less extensive, of the reflected folds of the membrane to each other; and I have observed occasionally, in dissection, such partial adhesion as might reasonably be supposed to have arisen from inflammation at some former period. The slight adhesion of the cartilage to the bone, in the first of the cases which have been related, and the partial absorption of the cartilage in the last case, we must suppose to have been the consequence of the greater disease in the synovial membrane. In another case, in which the patient, 6 OBSERVATIONS ON THE having recovered of inflammation of the synovial membrane, died several months afterwards of another disease, I found, on dissection, that the greater part of the cartilage of the patella, and a small portion of that covering the condyles of the femur, had disappeared, and that its place was occupied by a thin yellow membranous substance adhering to the bone, and forming a distinct cicatrix. I have known many cases in which there was extensive destruction of the cartilages of a joint by ulceration, manifestly arising from neglected inflammation of the synovial membrane. That this should hap- pen, is no more remarkable than that ulcer of the cornea should occasionally be induced by inflammation of the tunica conjunctiva of the eye. At the same time, I believe it will be found, in the majority of cases, of caries of the joints, that the disease has begun in the harder textures, and that the inflam- mation of the synovial membrane by which it is accompanied, is a secondary affection, the consequence of the formation of an abscess in the articular cavity. Inflammation of the synovial membrane occasionally terminates in suppu- ration, without having induced ulceration of either the soft or hard textures of the joints. I found this to have happened in the case of a patient who died in consequence of a small wound, which had penetrated into the elbow, the joint being full of pus, although there was no ulcerated surface. The same thing occasionally occurs where the inflammation has not had its origin in a mechanical injury. There is a peculiar morbid state of the system, which, in some instances, follows severe accidents, or operations, and which is well known to surgeons who are engaged in the practice of the London Hospitals, in which the patients are liable to deposits of pus in various parts of the body, at a distance from the seat of the original injury. These deposits not unfre- quently take place in the cavities of joints, as a consequence of inflamma- tion of the synovial membrane, and independently of ulceration. Several examples of the kind have fallen under my own observation; but it will be sufficient for me to refer to those which have been recorded by the late Mr, Rose, and by Mr. Arnott, in the fifteenth volume of the Medico-Chirurgical Transactions. In one of the cases related by Mr. Arnott, it is stated that the cavity of the knee-joint was filled with a " tolerably thick pus, of an uniformly reddish color, as if from an admixture of blood." The following case affords a still more remarkable example of the secretions of an inflamed synovial mem- brane being tinged in the same manner. Case IV.—Henry Payne, thjrty-nine years of age, was admitted into St. George's Hospital, under the care of Mr. Hawkins, on the 7th of October 1829. He had suffered, formerly, from repeated attacks of rheumatism. .$ About twelve weeks ago, after exposure to damp and cold, he was seized with inflammation in nearly all his joints. In the course of a few days, the disease in the other joints had abated; but the right knee became more pain- ful and swollen. At the time of his admission, this knee was tender, painful and much distended with fluid, and there was a good deal of febrile excite- ment of the system. Blood was taken from the neighborhood of the knee by cupping ; and this was followed by the application of blisters. The vinum colchici, and after- wards calomel, combined with opium, were administered internally. Under this treatment the pain and swelling of the knee subsided. On the 27th of October, he was attacked with severe inflammation of the DISEASES OF THE JOINTS. 1 fauces and larynx; which, however, soon yielded to the remedies em- ployed. On the 31st, he complained of severe pain in the right side, with great difficulty of breathing; and on the 3d of November he died. On examining the body after death, the pleurae were found inflamed, and incrusted with lymph, and serum had been infused into that of the right side. The lungs, also, were inflamed, and some portions of them were in a state of gangrene. The heart was affected with hypertrophy, and the pericar- dium was inflamed with flakes of lymph adhering to it. The synovial mem- brane of the right knee was full of a dark colored fluid ; not purulent, but having the appearance of a thick synovia, tinged with blood. The synovial membrane was every where of a red color, as if stained by this secretion, and the cartilages of the joint had the appearance of having been stained in the same manner. There were some small extravasations of blood in the eellu-' lar membrane external to the joint* SECTION 11. On the Causes and Symptoms of this Disease. It is evident that inflammation may effect the synovial membrane of a joinf, by extending to it from some of the other textures of which the joint is com- posed, or that it may have its origin in the membrane itself. My present ob- servations are intended to relate chiefly to cases of the latter description; and what little is to be said, in addition, respecting those of the former, will be better introduced hereafter. Although no period of life is altogether exempt from this disease, it does not occur equally in persons of all ages. It very seldom attacks young children ; becomes less rare as they approach the age of puberty; and is very frequent in adult persons* This is the reverse of what happens with respect to some of the other diseases to which the joints are liable j and a knowledge of these circumstances will be found of some importance to the surgeon, in assisting him to form a ready diagnosis. Inflammation of the synovial membranes may take place, as a symptom of a constitutional affection, where the system is under the influence of gout or rheumatism ; where it is disturbed by the operation of the syphilitic poison; where mercury has been exhibited improperly, or in too large quantities; and under a variety ot other circumstances. But, in these cases, the disease, for the most part, is not very severe; it occasions a preternatural secretion of synovia; but does not, in' general terminate in the effusion of coagulated lymph, or in thickening of the inflamed membrane.- Sometimes it attacks several joints at the same instant, and even extends to the synovial membranes, which constitute the bursse mucosae and sheaths of the tendons. At o;her times it leaves one part to attack another, and different joints are affected in succession. In other cases, the disease is entirely local; produced by a sprain or other injury ; or the application of cold ; and sometimes arising from no evident cause. The application of cold is, on the whole, the most frequent source of the complaint; and hence it is easy to explain, why it occurs much more fre- quently in the knee than in any other joint j and why it is comparatively rare in the hip and shoulder, which are defended by a thick mass of muscles from the influence of the external temperature. Where the inflammation is thus 8 OBSERVATIONS ON THE confined to a single joint, it is more probable that it will assume a severe cha- racter, and that it may be of long duration. It is likely to leave the joint with its functions more or less impaired ; and occasionally terminates in its total destruction. In itself it is a serious disease, but it is often confounded, under the alarming name of white swelling, with other diseases which are still more serious. # Inflammation may take place in the synovial membranes in different de- grees of intensity ; but for the most part it has the form of a chronic or slow inflammation j which, while it impairs, does not altogether destroy, the tunc- tions of the joint; and which, if not relieved in the first instance, by active and judicious treatment, may, like a chronic ophthalmia, continue for weeks or months, and, with occasional recoveries and relapses, may even harass and torment the patient during many successive years. In the first instance, the patient experiences pain in the joint, which, al- though it affects the whole articulation, is often referred principally to one spot, being there felt more severely than elsewhere. The pain usually con- tinues to increase during the first week or ten days, when it is at its height. Sometimes even at this period the pain is trifling, so that the patient experi- ences but little inconvenience from it; at other times it is considerable, and every motion of the joint is distressing and difficult. In the course of one or two days after the commencement of the pain, the joint may be observed to be swollen. At first, the Swelling arises entirely from a preternatural collection of fluid in its cavity. In the superficial joints, the fluid may be distinctly felt to undulate, when pressure is made alternately by the two hands placed one on each side. When the inflammation has ex- isted for some time, the fluid is less perceptible than before, in consequence of the synovial membrane having become thickened, or from the effusion of lymph on its inner or outer surface ; and, in many cases, where the disease has been of long standing, although the joint is much swollen, and symptoms of inflammation still exist, the fluid in its cavity is scarcely to be felt. As the swelling consists more of solid substance, so the natural mobility of the joint is in a greater degree impaired. The form of the swelling deserves notice. It is not that of the articulating ends of the bones, and, therefore, it differs from the natural form of the joint. The swelling arises chiefly from the distended state of the synovial membrane, and hence its figure depends in great measure on the situation of the ligaments and tendons, which resist it in certain directions, and allow it to take place in others. Thus, when the knee is affected, the swellingis principally observa- ble on the anterior and lower part of the thigh, under the extensor muscles, where there is only a yielding cellular structure between these muscles and the bone. It is also considerable in the spaces between the ligament of the patella and the lateral ligaments ; the fluid collected in the cavity causing the fatty substance to protrude in this situation where the resistance of the external parts is less than elsewhere. In the elbow the swelling is principally observa- ble in the posterior part of the arm, above the olecranon, and under the ex- tensor muscles of the fore-arm ; and in the ancle it shows itself on each side, i«^he space between the lateral ligaments, and the tendons, which are situa- te|Plhjthe anterior part. In like manner in other joints, the figure of the swefnng, whether it arises from fluid alone, or joined with solid substance, depends in great measure on the ligaments and tendons in the neighborhood, and on the degree of resistance which they afford ; and these circumstances, though apparently trifling, deserve our attention as they enable us more readily to form our diagnosis. DISEASES OF THE JOINTS. 9 In the hip and shoulder the disease occurs less frequently than in the super- ficial joints ; and here the fluctuation of the effused fluid is not perceptible3 but the existence of swelling is sufficiently evident beneath the muscles. When the shoulder is affected, there is pain accompanied with a general tumefaction of the part; and, in most instances, if the hand be placed upon it, at the same time that the limb is moved, a crackling sensation is observed, which probably arises from an effusion of fluid into the cells of the neighboring bursa. After some time the swelling subsides, or the joint may even appear to be smaller than natural, in consequence of the muscles, especially the del- toid, having become wasted from want of exercise. When inflammation attacks the synovial membrane of the hip, there is an evident fullness of the groin, and, in some instances, of the nates also. There is pain, which is referred, not to the knee, as in cases of ulceration of the carti- lages, but to the upper and inner part of the thigh, immediately below the origin of the adductor longus muscle. The pain is aggravated when the patient stands erect, and allows the limb to hang, without the foot resting on the ground. It is also increased by motion, but not by pressing the articulating surfaces against each other-, so that it does not prevent the weight of the body being borne by the affected limb. The pain is often very severe, yet it does not amount to that excruciating sensation which exhausts the powers and spirits of the patient in whom the cartilages of the hip are ulcerated. From some cases, which have fallen under my observation, I cannot doubt that in- flammation of the synovial membrane of the hip, occasionally terminates in dis- location of that joint. It is easy to understand how this may happen, where the synovial membrane and capsular ligament are much distended and dilated, the round ligament being at the same time separated from one of its attach- ments by ulceration. The head of the femur, under these circumstances, would be pushed outwards until it had passed beyond the bony margin of the acetabulum, when the action of theglutaei muscles would draw it upwards, and cause it to be lodged on the dorsum of the ilium. An example of this kind of dislocation will be found among the cases which will be related hereafter. After inflammation of the synovial membrane has subsided, the fluid is ab- sorbed, and, in some instances, the joint regains its natural figure and mobility^ but, in other cases, stiffness and swelling remain. Sometimes the swelling Ws the same peculiar form which it possessed while the inflammation still ex- isted, and while fluid was contained in the joint; and we may then suppose, that it depends principally on the inner surface of the synovial membrane having a thick lining of coagulated lymph. At other times the swelling has the form of the articulating extremities of the bones.that is, nearly the natural form of the joint; and it probably arises from the thickened state of the syno- vial membrane. From whichever of these causes it be that a swelling remains after the inflammation has subsided, the patient is very liable to a recurrence of the disease. Whenever he is exposed to cold, or exercises the limb in an unusual degree, and often, without any evident reason, the pnin returns, and the swelling is augmented. In those cases in which the synovial n rrbrane b thickened, although the fluid, which had been effused, is absorbed, and t):f principal swelling has disappeared, it occasionally happens, not onlyjjl$ a certain degree of inflammation still lingers in the part, but that it cj^raj&3 until the morbid action extends to the other textures ; aid u 11 *m&jlfl PP^^ tion takes place in the cartilages, suppuration is estal>nsheA.ai«jpHWSfes^ complete destruction of the articulating surfaces. In this ai{J^nc4# '■'' '■}';<£%*. we wish to know whether the inflammation of the synovial niembrian '; or the ulceration of the cartilages, has been the primary affection, v. e must form ouT 2 10 OBSERVATIONS ON THE judgment, not from the present symptoms, but from the previous history of the case. It is, indeed, often difficult to procure a history on the accuracy of which we can rely, particularly in hospital practice ; but this is of the less im- portance, as whatever the disease may have been in its origin, where it has proceeded so far as has been described, there is no difference respecting the treatment 5 and, for the most part, when suppuration has taken place, there is little prospect of advantage from any thing, except the removal of the limb by amputation. I believe, that the above history will be found applicable to the majority of cases in which this disease exists" But I have before observed, that inflam- mation may exist in the synovial membranes in different degrees of intensity ; and occasionally it will be found to be more urgent in its symptoms, and to be more rapid in its progress, than what has been described ; having the charac- ters of an acute instead of a chronic inflammation. Under these circumstan- ces, the swelling takes place immediately after, or at the same instant with, the first attack of pain ; there is redness of the skin ; the pain is more severe ; and it is so much aggravated by the motion of the parts, that the patient keeps the joint constantly in the same position, and usually in an intermediate state between that of flexion and extension. In addition to these symptoms, there is more or less of symptomatic fever of the inflammatory kind. In a few days the disease, if left to itself, assumes the chronic form; or, perhaps, under proper treatment, it subsides altogether. It must be observed, however, that the boundaries of acute and chronic in- flammation do not admit of being very well defined. These terms accurately enough express the two extremes ; but there are numerous intermediate de- grees of inflammation, of which it is difficult to determine whether they should be considered as being of the acute or chronic kind. On this, and on many other occasions, the pathologist must be content if he can succeed in pointing out the principal varieties of morbid action which occur, and the symptoms which they produce, in such a manner as will enable others, with the assist- ance of a certain degree of original observation, to distinguish those nicer shades in the characters of disease, which language is inadequate to explain, but a knowledge of which is of considerable importance in medical and surgi- cal practice. It is to be supposed that the character which inflammation of the synovial membrane assumes must, in a great degree, depend on the peculiar constitu- tion of the patient. It is, however, modified by a variety of other circum- stances. I have already observed, that the symptoms are, for the most part, more severe, and that there is a greater disposition to terminate in the effusion of coagulated lymph, and thickening of the synovial membrane, where the in- flammation is strictly local, than where it is the result of some disease affect- ing the general system. * In syphilitic cases, it seldom happens that more than one or two joints are affected at the same time. In the early stage of syphilis, the inflammation is JjluaHy an accompaniment of a papular eruption.or lichen; there is then but ■toain ; fluid is effused only in small quantity ; and when this has become ■^* the joint is restored as nearly as possible to its original condition. H|re advanced stage of syphilis, we find it existing in combination with BWIkml nerc it is productive altogether of much more inconvenience to 0e psra%it; ragpiore difficult to be relieved; and the synovial membrane is left thickened, and the joint somewhat larger than natural, after the fluid has disappeared. In case3 of the last description, it is often impossible to deter- DISEASES OF THE JOINTS. 11 mine, whether the disease can with most reason be attributed to the agency of the syphilitic poison, or to the repeated exhibition of mercury. In cases of rheumatism, several joints are frequently affected, either at the same time, or in succession; and the synovial membranes which constitute the bursa mucosa and sheaths of the tendons, often participate in the disease. There is usually a good deal of pain and swelling, and the joints are often left stiff'and enlarged afterwards. Where the inflammation is connected with gout, the pain is generally out of all proportion to the other symptoms of in- flammation ; and the patient compares his sensations to those, which might be supposed to arise if the joint were compressed by a vice, or if it were violently torn open. There is a remarkable, yet not uncommon form ol the disease, which may be considered as bearing a relation to both gout and rheumatism, but differ- ing from them, nevertheless, in some essential circumstances. The synovial membrane becomes thickened, so as to occasion considerable enlargement of the joints, and stiffness, there being; at the same time but little disposition to the effusion of fluid. In the first instance, the disease is often confined to the fingers ; afterwards it extends to the knees and wrists ; perhaps to nearly all the joints of the body. Throughout its whole course, the patient com- plains of but little pain; but he suffers, nevertheless, great inconvenience, in consequence of the gradually increasing rigidity of the joints, and the num- ber which are effected in succession. The progress of the disease is usually very slow, and many years may elapse before it reaches what may be regarded as its most advanced stage. Sometimes, after having reached a certain point, it remains stationary, or even some degree of amendment may take place: I do not, however, remember any case in which it could be said that an actual cure had been effected. The individuals who suffer in the way which has been described, are, for the most part, those belonging to the higher classes of society, taking but little exercise, and leading luxurious lives; but there are exceptions to this rule, and the disease occasionally occurs in hospital practice; in men, and even in females, of active and tem- perate habits- SECTION III. On the Treatment of this Disease. In cases in which inflammation of the synovial membrane is connected with rheumatism, those remedies maybe employed with advantage, whifH are useful in relieving rheumatism in other textures; such as opium combiu*i with ipecacuanha, or other diaphoretics; preparations of the colchicum autum- nale and mercury. Of the two latter, I have found reason to believe th^ the colchicum is to be preferred, where several joints an itffected^^> where the synovial membranes, which constitute the bar,a JWtfr sheaths of the tendons, participate in the disease. T > -uch f^P of the root of colchicum maybe administered in d ■■-• •- > '■' > ii minims, three times daily, or in some instances, tiit u< etoujp' cum may be given in alterative doses of 2 or 3 r.nins e>*. the other hand, mercury is preferable where only urn: r tw% at a time; but where there has been a manifest'^r-slaflk either from some internal organ, or from one joint u, ;n '■-■*l 4&* 12 OBSERVATIONS ON THE mercury, most generally useful under the circumstances, is that of calomel combined with opium; and it should be administered in such doses as to effect the gums, or to produce some other indication of its action on the general system. In those cases in which the patient complains of an excruciating grinding pain, or of a sensation as if the joint were torn open, and in which I have already stated that the disease probably bears some relation to gout, the relief produced by the exhibition of colchicum is even more remarkable than in cases of rheumatism; being, in some instances, almost immediate, after leeches and other remedies have been employed to no purpose. Where inflammation of the synovial membrane arises from syphilis, it will probably disappear under a well regulated course of mercury; and where it seems to have arisen from the protracted or injudicious use of mercury, or from mercury acting on a peculiar constitution, sarsaparilla may be given with advantage. This last medicine is especially useful where the affection of the joints occurs in combination with diseases of the bones and perios- teum. In cases of that peculiar chronic disease, which is described in the con- cluding part of the last section, in which many joints, and sometimes nearly all the joints of the extremities are effected in succession, it is of importance that the greatest attention should be paid to the general health, so that it may be maintained in as good a state as possible. As long as he is capable of doing so, the patient should take sufficient exercise daily, to induce a moderate degree of perspiration; he should live on a simple diet, avoiding especially raw fruit and acids, and whatever is not of easy digestion; and taking fermented liquors only in small quantity. The bowels should be kept gently open by means of rhubarb, or compound decoction of aloes, or some other of the same class of aperients. It has appeared to me also that, in these cases, patients have derived benefit from the use of acetous extract of colchicum, exhibited at intervals of six or eight weeks, for 10 or 12 succes- sive nights, in small or alterative doses; and still more from the long-continued use of alkalis. The carbonate of potash usually agrees with the stomach better than the pure potash. Ten or fifteen grains may be given twice daily, in the middle of the day and evening, and continued, with occasional inter- missions for many months. But specific remedies are applicable to only a limited number of cases. For the most part, the disease is to be subdued by being treated as a simple local affection, and in no instance is such kind of treatment to be altogether neglected. In the acute form of the inflammation, leeches may be applied in the neighborhood of the part affected ; and if there be much symptomatic fever, blood may be taken from the arm, and the bleeding may, or may not, be repeated, according to circumstances. Attention should be paid to the state cT ihe bowels, and saline draughts maybe given with some diaphoretic medi- If the swelling has rapidly risen to such a height as to occasion con- l- ensioi: of the soft parts, the pain will be best relieved by means of 'w>||tations and poultices; but otherwise cold evaporating lotions ^*» a better effect. Under this treatment the acute inflamma- l mem'*rane in general speedily subsides. aimna'ion is relieved more slowly. In the first instance, i kepi ;n a state of perfect quietude. Blood should be %- '^pt, by means of leeches or cupping. The latter method is H'«---3$f^. Jjfsudden abstraction of blood, which can be thus effected, DISEASES OF THE JOINTS. 13 being more beneficial than the more gradual haemorrhage which is procured by leeches. It will in general be right to repeat the blood-letting twice or three times, or even oftener ; and, in the intervals, compresses may be laid on the part, moistened with some cold lotion. When the inflammation has been in great measure subdued, a blister may be applied; and, if necessary, several blisters may be employed in succession, with more advantage than a single b'isier k«:p- open by means of savin?, ccrr.'.z. The1 blisters should be of a considerable size; and if the affected joint be deep-seated, they may be applied as near to it as possible ; but otherwise a blister is frequently of more service when applied at a little distance. For example, if the synovial membrane of the hip be inflamed, the blister may be placed on the groin or nates; and if the disease be in the wrist, it may be applied to the lower part of the fore-arm. Under this treatment the pain is usually relieved; and in a few days the swelling, as far as it depends on fluid collected in the joint, is much diminished. Even when the tumor is solid, arising from the effusion of coagulated lymph, it will in a considerable degree subside, and sometimes be entirely dispersed, provided that the lymph has not yet become organised. Blisters are of more service, with respect to the removal of the swelling, than any other remedies; but they should not be employed without the previous abstraction of blood, except when the inflammation is slight, and when fluid is effused without any admixture of solid substance. When I have seen the knee joint much distended, I have, in some in- stances, ventured to evacuate the fluid by puncture; and the following is the result of my experience as to the effects of this operation:— 1st. In a thin person, if a few punctures be made with an instrument, a very little broader than a couching needle, by means of an exhausted cupping glass applied over the punctures, a large quantity of fluid may be easilv ab- stracted without the smallest danger, and with no inconsiderable relief to the patient. But while inflammation exists, the relief is not permanent; the fluid being rapidly regenerated ; so that in a day or two, or perhaps in a few hours, the swelling is as large as ever. If, on the other hand, the inflammation be already subdued, the absorption of the fluid usually goes on so rapidly, that any more expeditious method of removing it is unneces- sarv. 2dly, If suppuration has taken place in the joint (not in consequence of ulceration, but from the surface of the synovial membrane), a free open- ing made into it with a lancet will often be attended with the best effects. I have known, under such circumstances, anchylosis to become established, almost immediately, and the patient to obtain a speedy cure with an anchy- losed joint. The most prudent method of proceeding, is to make a punc- ture with a needle first, and allow a small quantity of fluid to escape, so as to ascertain its nature. If it be not simply turbid serum, but actual pus, the lancet may be used afterwards. When the inflammation is in great measure relieved ; liniments, which lr- rilate the skin, may be rubbed on twice or three times in the day. Most of the liniments of the Pharmacopoeia are not sufficiently stimulating for this, nor, indeed, for other purposes. The liniment urn camphora composilum may be employed pure ; or the linimenlum saponis may be made stronger by the addition of liquor ammonia and tinctura lytta ; and the powers of the linimen- twn ammonia may be augmented in the same manner, or by the addition of the oleum terebiiithina. The following liniment is more stimulating than, those in common use ; and as its effects are more permanent, it seems to me, in many cases, to be productive of better effects, with respect to the disease. 14 OBSERVATIONS ON THK pOlei Olivse giss. Acidi Sulphurici «>iss. Olei Terebinthinos 3iss. Fiat linimentum. It may be used of this strength for the class of persons who apply at a hos- pital for relief; but for those of a higher class in society, in whom the cuticle is generally thinner, and the cutis more tender, the proportion of the sulphu- ric acid should be somewhat less. The effect of this liniment is to excite some degree of inflammation on the skin ; the cuticle becomes of a brown color, and separates in thick, broad scales j and the inflammation of the internal parts is relieved, probably on the same principle as by a blister. Another liniment, which is also very useful, is one frequently recommended, consisting of a dram (or more) of the antimonium tartarisatum mixed with an ounce of the unguenlum cetacei. This produces a pustular eruption of the skin ; which, like other eruptions of the same kind, runs its course, and, during a certain period of time, operates very beneficially by abstracting the inflammation from the other parts. Stimulating piasters, such as the emplastrum ammoniaci cum hydrargyro, act on the same principle as stimulating liniments, and are useful under the same circumstances, but they are, on the whole, a less convenient ap- plication. Issues and setons may be of some service in chronic cases, in abating the 9ymptoms of inflammation of the synovial membrane ; but they are more especially beneficial where there is reason to believe that a secondary disease has begun to exist in the form of ulceration of the cartilages ; and of their use, under these circumstances, I shall have occasion to speak hereafter. No other active remedies seem to be productive of much benefit. But a great deal may be accomplished by mere negative treatment. Not only in cases of inflammation of the synovial membrane, but in all other cases in which actual disease of a joint exists, the disease, whatever it may be, is kept up and aggravated by motion and exercise ; and whatever means can be em- ployed so as to keep the joint in a state of complete repose, will go far towards the production of a cure. In the early stage of acute inflammation of the synovial membrane, indeed, no interference on the part of the surgeon is ne- cessary for this purpose ; the pain which the patient experiences on every at- tempt made to use the limb being sufficient to prevent him using it. But it is otherwise when the inflammation has in a great degree subsided. At this period the motion of the joint occasions little or no inconvenience at the time, although it invariably tends to aggravate the symptoms afterwards. It is difficult to persuade a patient thus situated to submit to a very rigid system of confinement; and if he should do m>, there is always danger, in protracted cases, that his general health may suffer in consequence. It is important that he should not be altogether deprived of the opportunity of taking air and ex- ercise yet it is necessary that the affected joint should be kept in a state ap- proaching as nearly as possible to one of complete repose. This double object may be attained by means of a proper bandage: applied so as to restrain the motions of the joint, at the same time that it makes no more than a moderate degree of pressure on it. As to the best mode of carrying this plan into exe- cution, the surgeon must exercise his own judgment in each individual case. If the disease be far advanced, and there is danger of the cartilages being ulcerated, he will find it prudent to restrain the motions of the joint altogether, by the application of pasteboard splints, confined by a roller, or even by cir- DISEASES OF THE JOINTS. 15 cular stripes of adhesive plaster on their outside. In other cases, the bandages, &c, recommended by Mr. Scott, in h s ingenious work on the diseases of the joints, will be productive of the best results.* There is a bandage which is very well suited to cases of this kind, which, in one part of its circumference, is composed of a stiff leather, elsewhere of an elastic material, and secured by a lace or buckles, so that it admits of being secured with any degree of tightness. If the seat of the disease be in the knee, there may be a single iece of leather, adapted to the shape of the posterior part of the limb ; it it e in the elbow, there may be a double piece of leather one on each side, and thus the construction of it may be varied so as to adapt it to any of the other articulations. In some instances much support may be wanted, and the leather should be stiff and unyielding: extending a considerable way above and below the joint. In others, where little support is necessary, the leather may be more pliant, and it should not extend beyond the immediate neighborhood of the part affected. Such a bandage is worn with the greatest comfort, and it fully answers the intended purpose. As it may be removed or applied by the f>atient's own hands, the use of it is quite compatible with that of the stimu- ating liniments which I have formerly mentioned.f Alter inflammation of the synovial membrane has entirely subsided, if we find the joint left with its mobility only in a slight degree impaired, we may very safely leave it to itself. Time and the restorative power of the constitu- tion will complete the cure. But if there be considerable stiffness and thick- ening of the soft parts a further application of blisters will often be useful in promoting the absorption of the lymph, which has been effused. I have also known much benefit to arise, under these circumstances, from the use of moxa in the way recommended by Mr. Boyle ; that is, the application of it being so managed, that the heat should penetrate into the soft parts, without making an eschar, and scarcely making a blister. At a still later period, friction made, by the hand, with starch, or other fine powder, will be productive of great advantage. The friction, however, should be employed with caution, as when used too freely, it sometimes occasions a return of the inflammation. Whenever there is the slightest indication of this being the case, it should be omitted, blood should be taken from the part, and some time should elapse before the friction is resumed. Friction is sometimes productive of very essential benefit, but not unless it be employed to a considerable extent; that is for two or three hours daily, and during a long period of time. It is, however, a remedy which is applicable only under certain circumstances. We must always bear in mind that friction is useful in relieving some of the effects of disease, but not disease itself; and those who recommend it without attention to this principle, in these and in other cases, will often find it to be productive of very injurious consequences. I have sometimes tried the effect of pumping hot water on a stiff joint, as recommended by Le Dran, and as now practised at some watering places. * A very convenient mode of applying bandages in these cases is as follows:—Let it be sup- posed that the disease is in the knee. Circular stripes of leather spread with the emplastrum, plumbi, are to be applied round the joint, and extending some way above and below it; cart- being taken that a space is left for the patella; on which there ought to be as little pressure as possible. Over this a calico roller (four or five yards for an adult) may be applied, and over this again a few circular stripes of linen, spread with adhesive plaster, with another calico roller over the whole. A bandage of this kind, carefully adjusted, may not require to be changed for six or eight weeks, and is very convenient to the patient. f Bandages of this kind are made by Shoolbred &, Co., in Jermyn Street; and by Sparkes, in Old Bond Street. 16 OBSERVATIONS ON THE The blow of a column of water, falling from a height of several feet, produces considerable friction, even so as to excoriate the surface, with which are com- bined the relaxing powers of heat and moisture. This practice is certainly productive of benefit; but the observations just made apply to this as well as the other modes of producing friction. Whenever friction is useful, the vr.-or bath is useful also. The joint may be alternately bent, and extended, rubbed and champooed, while it is in the bath, and a degree of force may be applied to it, under these circumstances, which it would be unsafe to employ otherwise. All these methods of treat- ment, however, require time, and the exercise of much patience ; and whoever expects the stiffness consequent on a severe attack of inflammation of the synovial membrane to be speedily removed, will not fail to be disappointed. In some cases, where the inflammation has been unusually severe, or of unusually long continuance, complete anychylosis having taken place, no plan of treatment can be successful in restoring the motions of the joint, and the patient must submit to the inconvenience of a stiff* joint ever afterwards. SECTION IV. Cases of Inflamed Synovial Membrane. The cases, which I am about to relate, will serve to illustrate some of the observations respecting the inflammation of the synovial membranes, which I have already made ; and also to explain some circumstances which will be found to occur in practice, and which could not have been so well introduced in the general history of the disease contained in the preceding pages. Who- ever will take the pains to compare these cases with each other, and with those which I shall relate hereafter, will,if I am not exceedingly mistaken, be con- vinced that the distinction of the different diseases of the joints is not a mere matter of curiosity, which may be interesting to the morbid anatomist; but that these diseases are different in their progress ; that they produce different symptoms, by which they may be known from each other in the living person, and which indicate the employment of different remedies for their relief. Case V.—John Adams, forty-seven years of age, on the 21st of August, 1811, was seized with a pain in his left Knee, and in the course of a few hours he found the joint to be swollen. This was accompanied by a slight attack of fever. On the 28th of August he was admitted into St. George's Hospital. At this time the knee was extremely painful and tender, and much swollen, the swelling not having the form of the articulating ends of the bones, but being most prominent on the anterior and lower part of the thigh, underneath the lower portion of Jje extensor muscles. The fluctuation of fluid might be dis- tinctly felt within the synovial membrane. Eight ounces of blood were taken from the knee by cupping. The loss of blood was immediately followed by an abatement of the pain, tenderness, and swelling. On the 30th of August, a blister was applied. The cupping was repeated on the 9th and 18th of September, and on the 4th of October ; and each time was followed by the application of a blister. On the 10th of October, the joint was free from all pain and tenderness. It was stiff, and still slightly swollen j but no fluid was perceptible, the swell- DISEASES OF THE JOINTS. 17 ing appearing to arise entirely from solid substance. He was directed to U3e a stimulating liniment twice in the day. On the 18th of October there had been no return of inflammation, and the stiffness and swelling were diminished. Friction was now employed, by means of the hand, with starch powder, every morning and evening ; and in a. few days afterwards, it was directed, in addition to the friction, that hot water should be pumped on the joint, so as to fall on it from a height of seve- ral feet for half an hour every morning. About the middle of November he was dismissed from the hospital ; the joint being now nearly as small, and as movable as before the inflammation had taken place. Case VI.—Robert Stewart, eighteen years of age, was admitted into St. George's Hospital on the 26th of January, 1814. He said that, about seven weeks before his admission, the right knee had become swollen and painful, without any evident cause. The pain and swell- ing took place about the same time. The pain was severe, and attended with some degree of fever. About a fortnight before his admission, the joint was cupped, and the swelling and pain became much diminished, and the leg more movable. The cupping had been repeated on the day previous to his com- ing to the hospital, and again afforded him relief. At the time of his being admitted into the hospital, the knee was still much swollen, the swelling extending up the anterior and lower part of the thigh under the extensor muscles ; and it appeared to arise chiefly from solid sub- stance effused within the articulation, very little fluid being to be distin- guished. There was but little pain or tenderness ; the joint admitted of a limited motion ; he said it was less stiff than it had been a short time before. On the 27th of January, eight ounces of blood were taken from the knee by cupping, and afterwards a blister was applied. On the 5th of February the blister was healed. The swelling was much diminished. The solid substance, which had been effused, was in great mea- sure absorbed ; so that the form of the articulating ends of the bones could be distinguished. The blister was repeated. On the 18th of February, the joint was scarcely larger than natural, but it was still stiff in a slight degree. The stiffness disappeared under the employ- ment of friction with mercurial ointment and camphor, and on the 23d of February he was dismissed from the hospital as cured. Case VII.—John Hannam, a stout middle-aged man, was admitted into St. George's Hospital, under Mr. Keate, on the 22d of May, 1811. He said that, six years ago, he had wrenched his right knee, which in a few hours became swollen and painful. In the course of a month the pain and the swelling subsided, and he returned to his duty as a soldier, in one of the regiments of Life Guards ; but from that period he experienced what he termed a weakness of the joint ; and he had a return of pain and swelling whenever he made any unusual exertion. A year and a half previous to his coming to the hospital, he was ill of a. fever. From this time the knee was^ mor? swollen and painful ; and he continued in this state, sometimes better, sometimes worse ; so that he was unable to do his duty, and he was in conse- quence discharged from his regiment. At the time of his admission the knee was swollen ; partly from fluid in its cavity, partly from thickening of the soft parts. The swelling extended some way up the anterior part of the thigh, and was prominent on each side of the ligament of the patella. The joint was stiff, but admitted of an imper- fect flexion and extension. He complained of some degree of pain when at 3 18 OBSERVATIONS ON THE rest; but the pain was more severe whenever he attempted to exercise the limb. There was an enlarged lymphatic gland in the groin. The knee was cupped several times, and always with advantage. Blisters and stimulating liniments were employed, and about the end of September, he left the hospital, better than when he was admitted ; but there was still pain whenever he made any unusual exertion, and the joint was swollen and stiff, though in a less degree than formerly. The swelling now appeared to arise altogether from solid substance, no fluid being perceptible. Fifteen months afterwards I had an opportunity of seeing the patient again. There was very little alteration in the state of the knee. He said that, whenever he took more exercise than usual, or was exposed to cold, in- flammation took place, and the swelling was increased ; but that, by remain- ing for a short time in a state of quietude, these symptoms were always relieved. The three preceding cases are sufficient.to illustrate the ordinary charac- ters, and the ordinary progress of this disease. Those which follow are in- tended to explain certain circumstances, which, although of less frequent occurrence, are occasionally met with, and which it is of much consequence for the surgeon to understand. Case VIII.—A young gentleman, about thirteen years of age, in July, 1817, was seized with inflammation of the synovial membrane of one knee, attended with the usual symptoms. Blood was taken from the knee by means of leeches and cupping, cold lotions were applied, and the violence of the inflammation subsided. In the beginning of October a blister was applied ; and, at the end of October, the knee was in the following state. It was larger than the other; the swelling having the form of the articulating extremities of the bones, and appearing to arise from a thickened state of the synovial membrane. The joint admitted only of a limited degree of motion, and the motion of it beyond a certain point was productive of pain. He was now directed to employ fric- tion with a stimulating liniment. The complaint continued very nearly in the same condition until the middle of November, when the swelling became suddenly reduced, and almost wholly disappeared. But on the same day he complained of an acute pain in his head, shooting from the temples to the forehead just above the eyebrow. This pain went off in a few hours, leaving only a slight soreness ; and for several days it returned periodically, in the form of a nocturnal paroxysm, of great severity, but of only a few minutes' duration. Leeches and blisters were applied both to the head and legs ; and purgatives were administered. At the end of a week the pain ceased ; but he was seized with great somno- lency, which was soon followed by strabismus, partial blindness, and almost total cessation of speech ; and, after remaining in this state about a week, he died. The body was not examined. Case IX.—James Burton, forty years of age, was admitted into St. George's Hospital on the 2d of June, 1813, laboring under a complaint of his left knee. He said that, two years ago, the joint became painful and swollen, at first in a slight degree, but afterwards the pain and swelling increased ; and he observed that the symptoms were always aggravated on the coming on of cold or wet weather. For the last nine months he had been unable to use the joint sufficiently to enable him to attend to his usual occupations. Blisters and is- sues had been employed at various times, and, as he thought, with some tem- porary relief. At the time of his admission the knee was swollen, in conse- quence of fluid being collected within the cavity of the synovial membrane. DISEASES OF THE JOINTS. 19 The fluid might be distinctly felt to fluctuate underneath the patella when the two hands were placed, one on each side of the joint. The soft parts were somewhat, but not considerably, thickened. He had very little pain except on motion ; was unable to bend the leg beyond the right angle, but could ex- tend it completely. The swelling of the joint appeared greater than it really was, on account of the wasting of the muscles of the thigh and leg. Blood was taken from the knee by cupping ; and afterwards several blisters were applied in succession. He took five grains of the pilula hydrargyri sub- muriatis composita every night. On the 2d of August a blister was applied, and kept open by dressing it with the savine cerate. At the end of three weeks he complained of pain, and a sense of irritation, extending up the thio-h and down the leg. These symptoms were attributed to the open blister, and' were immediately relieved when the blistered surface was allowed to skin over. On the 20th of September he quitted the hospital, being free from all his former symptoms, except that there was still a slight degree of stiff- ness of the joint. In the beginning of July, 1815, the same patient came again under my ob- servation. At this time, both knees were distended with fluid ; the right shoulder was swollen, but in a less degree ; and there was a collection of fluid in the synovial membrane which forms the sheath of the tendons on the posterior part of each wrist. On examining the right knee, which was the most swollen of the two, a sensation was communicated to the hand, as if produced by a number of small loose substances, of a soft consistence, within the cavity of the joint j and just perceptible to the touch. The joints were movable, and very little painful. He said that all these swellings had begun about three months after he formerly quitted the hospital, with a slight degree of pain, and had gradually increased.* . u• I suspect the loose substances, which were felt within the knee in this case, to have been portions of coagulated lymph, which had been effused on the inner surface of the synovial membrane, and afterwards had become de- tached; similar to those which are sometimes formed in the cavity of an inflamed bursa mucosa, and which I shall have occasion to describe hereafter. I had not the opportunity of observing the subsequent progress of the disease in this patient; and I have never been able to ascertain the correctness or incorrectness of this opinion, respecting these loose substances, by dissection. They are certainly of a different nature from the loose cartilages, which are met with in other cases. . . Case X.—Amy Brookes, fifty-four years of age, was admitted into St. George's Hospital on the 10th of June, 1818. Three years ago, her right knee became swollen and painful, and the pain and swelling had existed ever since, sometimes in a greater, sometimes in a less degree. At the time of her admission the knee was much swollen, in consequence of fluid collected in its cavity. There was pain in the joint, which was aggravated by mo- tion ; but which was not sufficient to interfere with her rest at night, or to prevent her going about her usual occupations. On examining the knee a sensation was given to the hand, as if some soft loose substance was formed * These cases are given as they stood in the former edition of this work, and as they sufficiently illustrate the principal circumstances in the history of the disease. But it should be observed, with respect to some of them (that of Burton and of Hannam, tor ex- ample) that the practice employed in St. George's Hospital for some years past, would have been, after the inflammation had subsided, to apply pasteboard splints or bandages, so as to restrain the motions of the joint, and that there is no doubt that the recovery of the patients under this treatment would have been more rapid and more complete. 20 OBSERVATIONS ON THE within the joint; and a crepitus was distinguished, on moving the patella from one side to the other. Daring the time of her stay in the hospital, blood was taken from the knee twice by cupping, and once by leeches; and two blisters were applied. July 15th, she was discharged as cured; there was no pain nor swelling ; the loose substance was no longer perceptible, and the crepitus could scarcely be distinguished. The crepitus which was observed in this case, occurs in a few instances, and I know not positively to what cause it is to be attributed. It is different from that which I have met with, where there has been reason to believe that the cartilages are destroyed, so as to expose the bone underneath ; and if this had been the cause of it, we must suppose that it would have been perma- nent, or, at any rate, of longer duration. Probably it may have depended, in this case, on an effusion of albumen (coagulated lymph), or on the synovia having been secreted of a different quality from what is usual. The following case affords an example of inflammation of the synovial mem- brane of the hip terminating in dislocation. Case XI.—Master L., being at that time about eight years of age, was at- tacked, towards the end of September, 1824, with what was believed at the time to be inflammation of one of the parotid glands, attended with a pod deal of fever. After six or seven days, and apparently in consequence of the application of cold lotions to the cheek, the inflammation left the parotid gland, and attacked one shoulder and arm ; and at the end of two or three days more it left the shoulder and attacked one of the hips. For six or eight weeks he suffered most severely from pain referred to the inside of the thigh, extend- ing from the pubes as low down as within two or three inches of the inner condyle of the femur, and attended with a great deal of fever. There was no pain in the knee. The surgeon, who was then in attendance, applied leeches to the hip, lotions, &c, and afterwards made an issue with caustic behind the great trochanter. The fluctuation of fluid was perceived at the posterior point of the hip, and it was supposed that an abscess had formed. However, no puncture was made, and the fluid gradually became absorbed. In March, 1825, Master L. was sufficiently recovered to be able to walk about; but it was discovered that the limb was shortened. In November, 1825, I was consulted respecting him. At this time there was all the marks of a dislo- cation of the hip upwards and outwards. The limb was shortened, the toes turned inwards, and the head of the femur was distinctly to be felt on the posterior part of the ilium above the margin of the acetabulum. The following case furnishes an example of a disease, which, as far as I know, has not been described by any pathological or surgical writer. One of the most remarkable symptoms which the disease produces, is an inflamma- tion of the synovial membranes; for which reason it is to be regarded as connected with the present subject, and may be properly introduced in this place. Case XII.—A gentleman, forty-five years of age, in the middle of June, 1817, became effected with symptoms resembling those of gonorrhoea. Tlit-re was a purulent discharge from the urethra, with ardor ur'moz and chordee. O.i the 23d of June he first experienced some degree of pain in his feet. On the 24tu the pain in the feet was rather increased, but not in a sufficient d gree to prevent his walking four miles. There was some appearance of innammatio i of his eyes. June 25th, the pain in his feet was more severe ; the tunica conjunctiva of his eyes were much inflamed, with a profuse discharge of pus. DISEASES OF THE JOINTS. 21 The symptoms increased in violence, the pulse varying from 80 to 90 in a minute ; the tongue being furred ; and the patient being restless and un- comfortable during the night. The whole of each foot became swollen ; there was inflammation of the synovial membranes of the ankles ; and it appeared to me, that the affection of the feet themselves arose from inflammation of the synovial membranes belonging to the joints of the tarsus, metatarsus, and toes. He said that he could compare the pain which he experienced, to nothing else than that which might be supposed to arise from the feet being squeezed in a vice. On the 27th of June the left knee became painful, and on the following day the synovial membrane of this joint was found exceedingly distended with synovia. He was now completely crippled ; compelled to keep his bed, and scarcely able to vary his position in the smallest degree without assistance. The inflammation of the eyes and urethra was somewhat abated. June 30th, the inflammation of the eyes and urethra had much subsided, and the purulent discharge was diminished. The pains of his joints were less severe ; and the feet were less swollen. On the following day the knee was less swollen also. He continued to mend, and on the 10th of July the swelling of the feet was still further diminished, and that of the knee had almost wholly disap- peared. His pulse continued to vary from 80 to 90 in a minute, and his tongue was still furred. He had pain in the feet and knee, but less severe than formerly, and he was restless at night. July 13th, he complained of pain in the right knee, and on the following day there was pain also of the right elbow and shoulder. The right knee afterwards became swollen from fluid within the cavity of the synovial membrane, but not in the same degree with the other knee, and the swelling soon subsided. There was never any perceptible swelling of the shoulder and elbuw. August 1st, all his pains were abated. The eye and the urethra were nearly free from inflammation, and the purulent discharge was scarcely per- ceptible. August 5th, he was free from pain except on motion ; the joints, which had been affected, were stiff"; but he was able to move about on crutches. From this time he progressively mended. The stiffness of the joints dimi- nished very slowly ; but he was free from all uneasiness. He was longer in recovering the use of the shoulder, than that of the other joints. In the following December, 1817 (at which time he had nearly, but not com- pletely, recovered the use of his limbs), he had another attack of the com- plaint. The symptoms were the same as formerly, taking place in the same order, and pursuing the same course, but with a much, less degree of violence. This second attack lasted about six weeks; and left him again considerably crippled. In March 1818, he became aff cted with an ophthalmia, but of a different nature from that which he labored under in the preceding summer. The inflam- mation was seated in the proper tunics of the eye; and it appeared probable that it would speedily have terminated in adhesions of the iris, and destruction of the powers of vision, if its progress had not been arrested by repeated blood-lettings and the use of mercury. He had another attack of ophthal- mia of the same kind four years afterwards (1822). In order that the history of the disease might be rendered as simple as pos- sible, I have described the symptoms in this case without hitherto adverting to the treatment which was employed.—Leeches, and blisters to the knee; li- 22 OBSERVATIONS ON THE niments rubbed on the knees and shoulders ; and fomentations when there was severe pain, formed the principal topical remedies. Of the various me- dicines which were exhibited, none seemed to be productive of benefit, with the exception of the vinum colchici. It was under the use of this medicine, that not only the pains and swellings of the joints, but that even the purulent inflammation of the eyes and urethra first began to subside: and I am on the whole, inclined to believe that my patient was indebted to it for a much more ■speedy recovery than he would have obtained otherwise. I have had the opportunity of seeing many other cases, in which a similar train of symptoms took place. One gentleman (at the time when these notes were taken) had as many as nine attacks of this complaint. The first took place when he was under twenty years of age, and the others at various intervals in the course of the next twenty years. In one of them the first symptom was inflamma- tion of the urethra, attended with a discharge of pus, although from particular circumstances, he could not believe that he had been exposed to the risk of infection. This was followed by purulent ophthalmia, and that by inflam- mation of the synovial membranes. In three of the attacks, a purulent oph- thalmia was the first symptom ; which was followed by inflammation and dis- charge from the urethra; and then the synovial membranes became affected: and in the other four attacks, the affection of the synovial membranes took place without any preceding inflammation either of the eye or urethra. The disease was not confined to the synovial membranes of the joints, but those of the bursae mucosae were inflamed also. In some of the attacks, the muscles of the abdomen were painful and tender, and subject to spasmodic contrac- tions ; and there was an occasional impediment to breathing, which seemed to arise from a similar affection of the diaphragm. The acute form of the dis- ease, in this case, lasted from six weeks to three months, but nearly a year generally elapsed before the use of the Hmb3 was perfectly restored. He had an attack in July, 1817 ; and in the beginning of May, 1818, while he was still lame, he was seized with a very violent inflammation of the sclerotic coat and iris of one eye, which was subdued by very copious blood-Iettino-, and the exhibition of mercury. He had an other attack of the disorder in the year 1820, and in the winter of 1822 he became affected with an inflammation of the iris and sclerotic coat of the other eye, which was also relieved by blood-letting and the use of mercury. Another gentleman gave the following history of his complaints. In the year 1809, he had symptoms resembling those of gonorrhoea ; and, when these had continued for some time, one testicle became inflamed and swollen. This was followed by a purulent ophthalmia, and inflammation of the synovial membranes. In the year 1814, he had a similar attack, with the exception of the swelled testicle; and in the year 1816, when 1 was consulted, he still la- bored under a chronic inflammation of the synovial membranes of the knees and ankles, the consequence of the last attack, and by which his lower limbs were completely crippled. In a fourth case, the patient labored under a severe ophthalmia, which was followed by inflammation of the urethra, and then the joints became affected • but I had no opportunity of watching the progress of this case, nor have I heard' any other particulars of it. In another case, the patient labored under strictures of the urethra. He had had four attacks of the disease, which has been just described, in the course of a few years. The inflammation of the urethra was in all of them the first symptom; which was followed by purulent ophthalmia, and afterwards by DISEASES OF THE JOINTS. 23 inflammation of the synovial membranes, and swelling of nearly all the joints. In two of these attacks, he attributed the discharge from the urethra to his having received the infection of gonorrhoea, and in the two others to the use of the bou-ie. I shall conclude this chapter with the histories of two cases, one of which bears a near relation to those which I have just described, and is introduced chiefly as it shows the good effects produced occasionally by the exhibition of the colchicum ; while the other affords an example of the advantage derived from the exhibition of mercury, under certain circumstances. Case XIII.—A gentleman, twenty-three years of age, in the beginning of July, 1819, rode 24 miles on horseback, trotting very hard on account of rain. Two days afterwards he observed a slight swelling of the left knee ; but this did not prevent his going about his usual occupations. About the middle of July, a slight purulent discharge took place from the urethra, with little or no pain. On the first of August, he walked a considerable distance, and found the knee to be more painful. On the 2d of August, he applied to me, with the knee very much swollen and very painful. Twenty leeches were applied, and afterwards a cold lotion ; but this gave him no relief. August 3d, the pain had much increased, so that it was excruciating. He was bled in the arm, and was in much less pain afterwards. Some saline medicine with the pulv. ipec. comp. was administered. In the evening a blis- ter was applied ; but, as soon as the blister began to act, the pain returned and was as severe as formerly. August 5th. he continued suffering very much from pain. August 6th, the pain was very intense in the knee. The purulent discharge from the urethra was rather increased. There was a slight degree of inflam- mation of the tunica conjunctiva of the left eye. He was bled, with little or no relief. A saline draught, with a few.grains of thepulvis ipecac, comp. and 20 drops of the vinum (radicis) colchici, was administered every six hours. When he had taken four doses of this medicine he became sick, and vomited, and was afterwards purged. The colchicum was discontinued. August 7th, he was quite free from pain, but the synovial membrane was much distended with fluid. August 15th, the knee had continued free from pain, but was much swollen. With°a view to promote the absorption of the fluid, another blister was ap- plied ; but, as soon as it began to produce its effect, the pain returned more excruciating than ever; and continued so on the following day, August 16th, when the vinum colchici was again administered. As soon as he had taken three doses of 20 drops each, he was sick and purged, and this was followed by an immediate and complete relief from pain. August 17th, he was free from pain, except on motion. August 18th, the swelling began to subside, and in the course of a few days it had entirely disappeared, and he was quite recovered. The inflammation of the eye subsided, without any particular local treat- ment, in about ten days from the period of its commencement. The purulent discharge from the urethra continued for some time afterwards. The pain in the knee, in this case, was of such a kind as to be almost insupportable. The patient said that he could compare it to nothing but the sensation which he might suppose to be produced by the joint being forcibly torn open. The pulse was never accelerated, except at those times when the pain was most intense. Purgatives and other remedies were administered in the course of the disease, but nothing seemed to be productive of benefit, except the vinum colchici. Case XIV.—John Welsh, thirty years of age, was admitted into St. George's Hospital, on the 21st of February, 1827. 24 OBSERVATIONS ON THE The right knee was much distended with fluid. He complained of con- stant pain in the joint, and of painful startings of the limb at night; by which he was frequently awakened from his sleep. The pain was aggravated by every motion of the joint, and by pressing the articulating surfaces against each other. The pulse beat 100 m a minute. He stated that, nearly five months ago, he had been a patient in the Mid- dlesex Hospital, on account of an inflammatory affection of his chest; and that blisters had been at that time applied to his side. As soon as the inflam- mation of the chest was relieved, both his knees became swollen and painful. He was then made an out-patient. The inflammation of the knees abated under the use of liniments ; but towards the end of December, 1826, the right knee became again inflamed, and continued until the period of his being admitted into St. George's Hospital. Blood was taken from the knee by cupping; and the pulvis ipecacuanha compositus was directed to be given every night. Afterwards the cupping was repeated, several blisters were applied in succession; and 3ss. of the vinum radicis colchici was ad- ministered three times daily for three successive days, when it was discon- tinued on account of it having acted considerably on the bowels. Under this treatment, however, little or no amendment took place with respect to the local disease, and the pulse rose to 108. March 17. I was led to suspect that the fluid in the joint might be puru- lent. In order to ascer ain this, I punctured the knee with a narrow sharp- pointed instrument; and by applying a cupp ng glass over the puncture, drew off between two and three ounces, not of pus, but of turbid serum, with small flakes of coagulated lymph floating in it. March 20. The fluid had become again collected in the joint, so that the swelling was as large as ever. The pain, however, had been manifestly re- lieved by the puncture. Pulse 110. The man complained of pain, referred to the right ulna and to the forehead, which he said he had felt for the last week. He was directed to take the following pill three times daily:— R. Hydrargyri submuriatis, gr. ij. Opii gr. ss. Fiat pilula. March 27. The pains in the head and ulna were relieved. The knee was less swollen and painful. Pulse 100. The gums were beginning to be sore. It was directed that the pill should be taken twice daily. March 31. The knee was much improved. Pulse 88. It was ordered that the pill should be taken only once daily. April 10. After having been quite free from pain in the knee, he had a slight recurrence of it; on account of which, it was thought advisable to apply leeches, and afterwards a blister. From this time he continued to mend. April 28. The mercurial pills were discontinued, and soon afterwards he was dismissed as cured. DISEASES OF THE JOINTS. 25 CHAPTER II. ON ULCERATION OF THE SYNOVIAL MEMBRANE. When an abscess has formed in a joint, an ulcerated opening takes place in the synovial membrane, through which the matter is discharged. The fol- lowing are the only cases, which have come under my observation, in which ulceration of the synovial membrane has occurred as a primary affection. The most remarkable circumstance which they demonstrate is, that a disease ap- parently slight, and of a part which is in no way concerned in the vital func- tions, should produce such a degree of disturbance of the constitution, as to occasion death. Of this, however, they form, by no means, a solitary exam- ple ; and every surgeon and physiologist will be able to call to mind numerous other instances, which show that an impression made upon a small part of the nervous system may derange, and ultimately destroy, the functions of the whole animal machine. Case XV.—A young lady, nine years of age, being at play on the 1st of January, 1808, fell and wrenched her hip. She experienced so little uneasi- ness, that she walked out on that day as usual. In the evening she went to a dance ; but while there was seized with a rigor; was carried norae and put to bed. Next morning she was much indisposed, and complained of pain in the thigh and knee. On the following day she had pain in the hip, and was very feverish. These symptoms continued 5 she became delirious; and she died just a week from the time of the accident. On inspecting the body on the following day, the viscera of the thorax and abdomen were found in a perfectly healthy state. The hip joint on the side of the injury contained about half an ounce of dark-colored pus ; and the sy- novial membrane, where it was reflected over the neck of the femur wax destroyed by ulceration, for about the extent of a shilling. Case XVI.—A middle-aged man, who had met with a contusion of one shoulder, was admitted into St. George's Hospital in the winter of 1812. He complained of pain and tenderness of the shoulder, and a very slight degree of swelling was observable: but his principal disease was a fever, resembling typhus in its character, of which he died in a few days after his admission. On inspecting the body, about half an ounce of thin pus was found in the shoulder-joint. The synovial membrane bore marks of general inflammation, and in one spot, where it was reflected over the neck of the os brachii, it wa* destroyed by ulceration for about the extent of a sixpence. 4 26 OBSERVATIONS ON THE CHAPTER III. ON CASES, IN WHICH THE SYNOVIAL MEMBRANE HAS UNDERGONE A MORBID CHANGS OF STRUCTURE. SECTION I. Pathological Observations. There are some diseases, which consist simply in a morbid action; there are others, in which the morbid action produces a morbid change of anatomical structure. Diseases of the latter class differ in their nature in different organs. Thus the tubercles, which affect the lungs in phthisis pulmonalis, are never met with in the breast: and cancer, which is frequent in the breast, never attacks the lungs, except by extending to them from the contiguous parts. The disease, which I am about to describe in the present chapter, consists in a morbid alteration of structure, which takes place in the synovial mem- branes of joints, and which, as far as I have seen is peculiar to these parts. I have never known an instance of the same disease in the serous membranes, which so nearly resemble the former in their nature and functions ; nor even in the synovial membranes, which constitute the bursse mucosa? and sheaths of the tendons. Several years since, in examining a diseased elbow, I found the cartilagin- ous surfaces completely destroyed by ulceration: an abscess had formed in the joint, and no remains were observable of the natural structure of the soft parts, these being everywhere converted into a pulpy substance, of a light brown color, and about one third of an inch in thickness. As the ravages of the disease were very extensive, it was impossible to determine, from the ap- pearances on dissection, where the morbid action had originated. This case, however, differed materially from some others which I had met with, in which the destruction of the cartilages was not attended by any affection ot the soft parts similar to that which has been described. The following cases, which have since occurred, furnish examples of the same disease in earliei stages of its progress, and show that it begins in the synovial membrane, and that the other parts become affected only in a secondary manner. Case XVII.—In a diseased knee, which was sent to me for examination by my friend the late Mr. Horn, surgeon to the Newcastle Infirmary, I found, in the cavity of the joint, about four ounces of a pale yellow fluid, havino- flakes of coagulated lymph floating in it. The synovial membrane, where it formed the loose folds, extending from one bone to the other ; where it was reflected over the bones themselves, the crucial ligaments, and the fatty substance of the joint, had completely lost its natural appearance. It was converted into a pulpy substance, in most parts about a quarter, but in some parts, nearly DISEASES OF THE JOINTS. W half an inch, in thickness, of a light brown color, intersected by white mem- branous lines, and with red spots formed by small vessels injected with their own blood. The synovial membrane on the edge of the cartilaginous surfaces had undergone a similar change of structure, but only for a small extent. The semilunar cartilages were entire, but in a great measure concealed by the pulpy substance projecting over them. The cartilages covering the bones, in a few places were in a state of incipient ulceration. Case XVIII.—Martha Manners, twenty-six years of age, was admitted into St. George's Hospital, on the 6th of March, 1813, on account of a disease '^ her right lcnee. She said that in June, 1811, she first observed the joint to be swollen ar.ct stiff; and from this time, the swelling and stiffness increased ; but, in the firct instance, by very slow degrees. About Michaelmas, 1812, she caught cold, and the swelling increased more rapidly ; but it was not attended with any considerable quantity of pain. At the time of her admission into the hospital, the right knee measured' about two inches in circumference more than the left. The swelling was elastic ; prominent at the upper and lower part of the joint; not having the form of the articulating ends of the bones. The joint admitted of motion, but the leg could not be completely bent or extended on the thigh. Various remedies were employed without the smallest benefit. The stiff- ness of the joint increased. About the middle of May, she began to experi- ence considerable pain ; and soon afterwards an abscess presented itself by the side of the ligament of the patella, which was opened on the 15th of June. The orifice made by the lancet healed in a few days ; but she continued to suffer severe pain ; her health became much affected, and on the 6th of Au- gust the limb was removed by amputation. On examining the joint, about an ounce of thick matter was found in ite cavity. The ligaments were in a natural state. The synovial membrane had undergone precisely the same alteration as in the case which has just been re- lated. The only point of difference that could be observed was, that the whole of that portion of the membrane which is reflected over the cartilages had become affected, presenting the same appearance as elsewhere, but being thickened in a less degree. The cartilages had begun to ulcerate in a few spots ; but the ulceration had made so little progress, that it might not have been noticed on a superficial inspection. Case XIX.—Samuel Langford, twenty-four years of age, was admitted into St. George's Hospital on the 22d of April, 1812. At the time of his admission one of his knees was swollen to nearly twice its natural size. The swelling was prominent on the anterior and lower part of the thigh. It was soft and elastic, so that at first it appeared to contain fluid ; but, on particular examination, the absence of fluid was ascertained by the want of fluctuation. The leg was kept in the half-bent state, and the joint admitted of only a very limited degree of motion. He had no pain, even when attempts were made to move the limb. The skin over the diseased part was of a pale color, with some dilated veins ramifying in it. On each side of the joint a small orifice was observed, through which the probe might be in- troduced into a sinus; but the sinuses appeared to be of small extent. T!is general health was unimpaired. He said that, two years ago, he first experi enced some pain in the knee, but it was not sufficient to prevent his goinc about his usual occupations. Soon afterwards the joint began to swell, and the enlargement gradually increased from that period. Several abscesses had formed at different times; but the greater number of them had healed. 28 OBSERVATIONS ON THE About two months after his admission into the hospital, the limb was ampu- tated. On dissecting the diseased joint, the ligaments were found in a perfectly natural state. The whole synovial membrane, except where it was reflected over the cartilages, was converted into a pulpy, elastic substance, of a brown color, intersected by white membranous lines, in some places half an inch in thickness,in others more; and in those parts where the membrane was re- flected over the bones, near the border of the cartilages, it was destroyed in spots by ulceration. The semilunar cartilages were in a natural state, but in a great measure concealed, in consequence of their being enveloped in the mass of substance formed by the diseased synovial membrane. The cartilaginous surfaces of the femur and patella were extensively, but not entirely, destroyed by ulcera- tion ; the ulceration being greatest towards the circumference. On the inter- nal portion of the head of the tibia, the cartilage was destroyed only for a very small extent, the ulceration being entirely confined to the margin. On the external portion of the head of the tibia, the cartilage was absorbed to a greater extent. The bones possessed their natural structure and hardness. The cavity of the joint contained matter, and the sinuses communicated with it. Case XX.—Michael Purcel, sixteen years of age, was admitted into St, George's Hospital, on the 10th of July, 1811, on account of a disease in the right knee. He said that, in the summer of 1807, he had received a blow on the inside of the joint. Some time afterwards a swelling formed and burst, and some fluid was discharged. In about a week the orifice healed; a slight degree of stiffness only remained and he was able to follow his usual occupations. He continued well till December, 1810, when the joint was observed to be in- creased in size. From this time the swelling increased, but with no other in- convenience than stiffness of the joint, and a slight degree of pain in walking At the time of his admission into the hospital there was a large swelling of the knee, extending an inch or more up the anterior part of the thigh under the extensor muscles. The swelling was more prominent in some parts than in others. It was soft and elastic, and gave to the hand an indistinct sensation as if it contained fluid. The leg was kept in a half-bent position, and was nearly immovable on the thigh. He had no pain, except on motion or pressure. On the 28th of November, an abscess burst on the outside of the joint, and discharged a small quantity of pus. After this other abscesses formed, and burst at various times. The swelling continued to increase. Amputation was performed on the 6th of April. On dissecting the amputated joint, all the ligaments were found in a natu- ral state. The synovial membrane had precisely the same appearance as in the last case. In some parts it was half an inch, in others more than an inch, in thickness. The cartilages were for the most part destroyed by ulceration, and carious* surfaces of bone were exposed. The abscesses appeared to have formed in the substance of the synovial membrane, and did not communicate with the cavity of the joint, nor did the joint contain pus. Case XXI.—A boy, six years of age, was admitted into St. George's Hos- pital, in March, 1808, on account of a disease in one knee. * In using the term caries, on this and other occasions, I have considered it as synonymous with ulceration; or, at least, as expressing that state in bones, which corresponds to ulcera- tion in soft parts. Some confusion has been produced in pathological nomenclature in conse- quence of tins term having been employed by some to express, not only bone which is ulcer ated, but that whose surface has been exposed from other causes. DISEASES OF THE JOINTS. 29 The joint was larger than the natural size. The leg was bent at a right angle to the thigh, and admitted of no motion. The skin on the outside was ulcerated to a considerable extent. Various remedies having been employed without success, the limb was amputated on the 29th of April. On examin- ing the joint, the synovial membrane was found to have undergone a morbid change of structure, similar to that in the preceding cases; but with this difference, that the pulpy substance into which it was converted projected into the joint, so as nearly to fill its cavity, and adhered to the cartilaginous surfaces. On making a longitudinal section of the joint, the cartilage cover- ing the bones was seen, as a white line, about one-tenth of an inch in thick- ness, connected to the bone on one side, and having the pulpy substance adhering to it on the other. It was, therefore, thinner than natural; but other- wise entire, except at the posterior part of one of the condyles of the femur, where it was destroyed by ulceration for a small extent. There were no distinct remains of the ligaments external to the joint, and only some small vestiges of the crucial ligaments and semilunar cartilages. Case XXII.—John Dillemore, thirteen years of age, was admitted into St. George's Hospital, in the summer of 1812, on account of a disease in one knee. At that time the joint was slightly swollen and stiff, so as to admit of only a very limited degree of motion. He was free from pain. The swelling was elastic, without any perceptible fluctuation of fluid. These symptoms had been coming on gradually about two years previous to his ad- mission. At this time he remained in the hospital for upwards of three months ; and a great number of remedies, which it is unnecessary to enu- merate, were employed without the smallest benefit On the 26th of January, 1814, he was re-admitted into the hospital. The affected knee was about two inches and a half in circumference more than the other. The swelling was elastic ; it extended up the anterior and lower part of the thigh, as in cases of inflamed synovial membrane ; but its form was less regular, being more prominent, and extending higher up on the outside than on the inside. The leg was kept in the half-bent position, and was perfectly immovable on the thigh. He was subject to occasional attacks of violent pain. He said, that the swelling had gradually increased from the period of his quitting the hospital, in 1812, but that he had not been subjeet to very severe pain till about six weeks previous to his re-admission. On the 31st of January the limb was amputated. On examining the diseased joint, the synovial membrane was found convert- ed into a pulpy substance of a light brown color, with red spots arising from vessels ramifying in it injected with their own blood, and intersected by very numerous membranous lines. On the outside of the joint, the diseased mem- brane was in some places nearly an inch in thickness. The membrane cover- ing the cartilages in some parts was in a natural state; in other parts, it had undergone the same morbid change of structure as elsewhere. The cartila- ges were ulcerated in spots. There was about half an ounce of pus in the cavity of the joint; and there were two or three abcesses in the substance of the synovial membrane, not communicating with the joint, containing about the same quantity of purulent matter. Case XXIII.—William Hine, twenty-three years of age, was admitted into St. George's Hospital on the 12th of December, 1814, on account of a complaint in one of his knees. He said that, in the summer of 1812, he first observed a slight degree of stiffness and swelling of the joint, unattended by pain. At first the swelling was confined to the inside, but it gra- dually extended itself over the whole circumference of the joint. The so OBSERVATIONS ON THE stiffness and swelling slowly, but uniformly, increased: and about the end of the year 1813, he began to experience considerable pain. At the time of his admission, the knee was much swollen ; the swelling was irregular and most prominent on the inside; it was soft and elastic, without &e fluctuation of fluid. The patient complained of constant deep-seated, gnawing pain, which disturbed his sleep. He had a slight degree of hectic Fever. On the 16th of December the limb was amputated. On dissecting the amputed joint, the synovial membrane was found to have undergone the same morbid alteration of structure as in the last case. The cartilages were slightly ulcerated in a few spots. Case XXIV.—James Gould, sixty-five years of age, was admitted into St. George's Hospital, in May, 1814. One knee was swollen and stiff, admitting of scarcely any motion. The swelling was elastic. He complained of severe pain in the joint. Near the ligament of the patella was the orifice of a sinus communicating with the articular cavity, and discharging a very small quan- tity of pus. No clear history could be procured of the disease in its earlier stages; but it appeared that he had been subject to repeated attacks of in- flammation of the synovial membrane. The limb was amputated on the 23d of May. On dissection, the ligaments, bones, cartilages, and that portion of the synovial membrane which is reflected over the cartilages, were found to be in a natural state j but the synovial membrane in other parts had undergone the same morbid alteration of structure as in the preceding cases. These cases furnish examples for the same disease in different stages of its progress. The morbid action evidently originates in the synovial membrane, v/hich loses its natural organization, and becomes converted into a thick pulpy substance of a light brown, and sometimes of a reddish-brown color, inter- sected by white membranous lines. As the disease advances, it involves all the parts of which the joint is composed, producing ulceration of the carti- bges, caries of the bones, wasting of the ligaments, and abscesses in different places. I have already remarked that this disease is peculiar to the synovial mem- branes ; at least, that I have never met with it in any other part of the body; but it belongs to the same order with tubercles of the lungs, scirrhus of the breast, the medullary sarcoma or fungous hsematodes of the testicle, and nu- merous other diseases, in which the natural structure of the affected organ is destroyed, and a new and different structure is added in its place. To these also it bears a near resemblance in its progress. Thus, tubercles of the liungs, in the first instance, occupy the vesicular and interlobular substance; but ultimately they inflame and ulcerate ; abscesses form in them ; and then the pleura, the bronchia, and other contiguous parts, become effected. Simi- tar circumstances mark the progress of other maladies of the same descrip- tion. The cases which have been related are not the only ones in which I have had the opportunity of tracing the same morbid appearances. I have also met with numerous others, in which the similarity of the history and symptoms, and the resemblance in the form and elasticity of the tumor, indicated the disease to be of the same nature, although I was not able to verify the fact by dissection. In every case, in which I have had it in my power to watch its progress, the complaint has advanced slowly, and sometimes has remained in an indolent state during a very long period: but ultimately it has always terminated in the destruction of the joint. It is a remarkable circumstance, that this affection of the synovial DISEASES OF THE JOINTS. 31 membrane is rarely met with except in the knee. I have never known an instance of it in the hip or shoulder.* It is probable that the influence of the external cold may operate as one of the causes by which the disease is pro- duced, and this explains, why it occurs frequently in the knee, and seldom in deep-seated articulations.! It is evident from the history of cases in which a part of the living body has assumed a new and morbid structure, that this alteration seldom takes place except by slow degrees; and it would add much to the interest and utility of researches in morbid anatomy, if it were more frequently attempted to ascertain, what is the first change in the organization of the affected part which disease produces, and from thence to trace the gradual progress of the other changes which take place, until the destruction of the natural organiza- tion is completed. Whether the following case is to be considered as of the same kind with those already recorded, but in an earlier stage of the, disease, cannot at present be determined ; but it appears not improbable that it is so; and I shall venture to relate it, in this place, in the expectation that it may, at any rate, be of some service in assisting the investigations of future inquirers. Case XXV.----Belton, a boy eleven years of age, was admitted into St. George's Hospital, in August, 1810, on account of a disease in one knee. There was but little pain in the joint: it was slightly enlarged, admitted of some motion, but not of complete flexion and extension. His parents said that the disease had begun about a year and a half before his admission into the hospital; that it had increased very slowly; and that he had never suffered from it any serious distress. Various remedies were employed without benefit; and in a short time his friends took him out of the hospital. A few weeks afterwards he died in consequence of an accumulation of water in the ventricles of the brain. I obtained permission to examine the body. The synovial membrane of the affected knee externally had its natural appearance. Internally it was lined by a straw-colored gelatinous sub- stance, so intimately adhering to it, that it could not be detached, except by an artificial separation. The synovial membrane was encrusted in this man- ner every where, except on the cartilaginous surfaces. The gelatinous substance in general appeared about one eighth of an inch in thickness, but in some parts, near the borders of the cartilages, it was much thicker, so as to project considerably into the cavity of the joint. In a few places, towards the margin of the articulating surfaces, the cartilage had begun to ulcerate ; in some of these it was entirely absorbed, so that the bone was exposed ; but for the most part, there was only an irregular ulcerated surface towards the cavity of the joint; the remaining portion of the cartilage being entire, and having its natural adhesion to the bone. The synovial membrane itself bore no marks of inflammation. In the sub- stance with which it was lined, some vessels were observed ramifying, beau- tifully injected with their own blood; but these were few in number, * My friend Mr. Hodgson, surgeon to the hospital at Birmingham, informs me that he has met with one example of it in the ankle, and another in one of the joints of a finger. f The account of the fungous articuli, which has been given by some German writers, appears to have been drawn, partly, from cases of the disease described in this chapter, partly, from cases of inflammation of the synovial membrane. Mr. Russel seems to have taken his history of the pathology of white-swelling in great measure from cases similar to those which have been related; but we must observe, that the term white-swelling has been applied, almost indiscriminately, to all the affections to which the joints are liable, and by no means confined to that under our present consideration. 32 OBSERVATIONS ON THE and only in certain parts. This substance differed in appearance from the coagulated lymph which is found on the surface of an inflamed membrane ; and we may presume, therefore, that the effusion of it was the result, not of inflammation, but of some other morbid action. SECTION II. On the Symptoms of this Disease. This disease generally takes place in persons who are not much above the age of puberty. I do not recollect more than one instance of it having occurred after the middle period of life. In general it can be traced to no evident cause, but occasionally it is the consequence of repeated attacks of inflammation. In this respect it resembles other diseases of the same order. Inflammation of the lungs may lay the foundation of tubercles, and inflam- mation of the breast may occasion the growth of a scirrhous tumor. Where I have had an opportunity of examining the morbid appearances after ampu- tation, I have always found the whole, or nearly the whole, of the synovial membrane affected by the disease ; but it is probable, that if the examinations were made at an earlier period, we should often find the morbid change originating in some one point. At least this is in conformity to what we find in other maladies, which correspond to this in their nature: and in one instance, in a girl who labored under this affection, and who died of a fever, I found one half of the synovial membrane altered in structure, and the other half retaining its natural appearance. In the origin of this disease, there is a slight degree of stiffness and tumefac- tion, without pain, and producing only the most trifling inconvenience. These symptoms gradually increase. In the greater number of cases, the joint at last scarcely admits of the smallest motion, but,in a few cases, it always re- tains a certain degree of mobility. The form of the swelling bears some resemblance to that in cases of inflammation of the synovial membrane, but it is less regular. The swelling is soft and elastic, and gives to the hand a sensation as if it contained fluid. If only one hand be employed in making the examination, the deception may be complete, and the most experienced surgeon may be led to suppose that there is fluid in the joint, when there is none ; but if both hands be employed, one on each side, the absence of fluid is distinguished by the want of fluctuation. The patient experiences little or no pain, until abscesses begin to form, and the cartilages ulcerate; and even then the pain is in many instances not so severe as where the ulceration of the cartilages occurs as a primary disease; and the abscesses heal more readily, and discharge a smaller quantity of pus, than in cases of this last description. At this period the patient becomes af- fected with hectic fever; loses his flesh, and gradually sinks, unless the limb be removed by an operation. The progress of this disease varies in different cases. In general, one or two years elapse before it reaches its most advanced stage; but sometimes the period is much longer ; and occasionally it becomes indolent, so that it remains during many months without any sensible alteration. In like man- ner, tubercles of the lungs, or scirrhus of the breast, in some instances, re- main in an inactive state for several months, or even for one or two years. The diagnosis of this disease is seldom difficult. The gradual progress of DISEASES OF THE JOINTS. S3 the enlargement and stiffness of the joint without pain, and the soft elastic swelling without fluctuation, in the majority of cases, enable us to distinguish it readily from all the other morbid affections to which the joints are liable. The cases with which those of this disease are most liable to be confounded, are those of chronic inflammation of the synovial membrane. 1st, When the synovial membrane has undergone a morbid change of struc- ture, it occasionally happens that a preternatural secretion of fluid takes place at the same time from its inner surface ; and the joint becomes distended, not with synovia, but with a turbid serum, having flakes of coagulated lymph float- ing in it, which causes the tumor to present nearly the same external charac- ters as where the synovial membrane is inflamed. But here the swelling will not yield to that treatment, under which it would be speedily reduced if it depended on simple inflammation ; and attention to this circumstance, joined with an accurate previous history, will enable us to recognise the real nature of the disease. 2dly, When the synovial membrane, after inflammation has subsided, has been left in a thickened state, and coagulated lymph has been effused into the articular cavity, the tumor, in some instances, a good deal resembles the tumor which occurs in cases of this disease; so much so, that it will be very difficult to give a correct opinion, merely from observing the present appear- ance and condition of the joint. The surgeon must in great measure form his judgment from the account which he receives of the origin and early symp- toms of the complaint; or, when an accurate statement cannot be procured, by waiting to observe its future progress. SECTION III. On the Treatment. When a part is swollen and rigid in consequence of inflammation, the swell- ing and rigidity may often be dispersed ; but I know of no instance in which an organ having completely lost its natural structure is capable of having that structure restored. Physicians and surgeons have been employed, during suc- cessive ages, in endeavoring to discover a cure for tubercles of the lungs, and cancer of the breast, and the result of their labor is only to prove that these diseases are incurable. Analogy, therefore, would not lead us to be sanguine as to the discovery of a remedy for this affection of the synovial membrane, and experience demonstrates that it is equally incurable with other maladies of the same order. It would be needless for me to occupy the time of my read- ers by a detail of the various remedies which I have tried, or seen tried by others, in cases of this description ; since the general result of these trials was only to lead to the above conclusion. By means of rest and cold lotions, the progress of the disease may be somewhat checked, as the suppuration of tuberculated lungs may be retarded by occasional bleeding, and a milder cli- mate. Where there is considerable pain in consequence of the cartilages having begun to ulcerate, some benefit is derived from the use of warm fomen- tations and poultices. But no method, with which I am acquainted, is capable of doing more than somewhat checking the progress, and somewhat relieving the symptoms of the complaint. In every case of which I have had an oppor- tunity of seeing the termination, the ulceration of the cartilages, the formation of abscesses in the cavity of the joint, and the consequent disturbance of the 5 34 OBSERVATIONS ON THE patient's general health, have ultimately rendered the amputation of the limb necessary, in order to preserve the patient's life. At this period, therefore, the surgeon is called upon to recommend and urge an operation ; but at an earlier period, it is a matter of choice with the patient, whether he will live with the incumbrance of an useless limb, till the advanced stage of the dis- ease renders its removal indispensable, or whether he will submit to the loss of it, before the absolute necessity for losing it exists. DISEASES OF THE JOINTS. 35 CHAPTER IV. ON THE ULCERATION OF THE ARTICULAR CARTILAGES. SECTION I. Pathological Observations. It has been taught by some anatomists, that the articular cartilages are not endowed with vascularity ; and that, when there is an appearance of their having been destroyed by ulceration, this must really have been effected, not by the action of vessels in the cartilages themselves, but by that of the vessels of the other parts, with which they are connected, or with which they come in contact. Various circumstances, however, seem to be in contradiction to these opinions. Up to the period of growth being concluded, we must suppose the articular cartilages to be vascular, otherwise we cannot account for the changes of bulk and figure which mark their progress towards complete development. In the child, canals or sinuses may be seen ramifying through their substance, contain- ing blood, and manifestly intended to answer the purposes, though not con- structed with the distinct tunics, of ordinary blood-vessels. In the adult person these canals for the distribution of blood, are not percep- tible. This proves that they are very minute, but not that they are altogether wanting. 1. In the transparent cornea of the eye no vascular structure can be detected under ordinary circumstances ; but the existence of vessels in the cornea is proved by the changes which it undergoes in disease; and when it is inflamed, such vessels become distinctly visible, injected with red blood. So we meet with occasional, though rare instances, of vessels containing red blood extending from a diseased bone into the cartilage covering it. A case, in which this appearance was observed, will be mentioned in the next chap- ter. 2. The cartilages of joints are subject to the constant and powerful operation of friction, yet they are not affected by it. They continue as thick and as perfect in those who are unremittingly engaged in bodily exercise, as in the most inactive persons. The cartilages of the knee and ankle are exposed to friction at least as much as the hard enamel and ivory of the teeth; yet we often see persons in whom the latter are much worn away, while the former remain entire. These circumstances cannot be explained, unless we admit the cartilages to possess a power of reparation ; and this must be sup- Eosed to depend, as in other textures, on the action of blood-vessels modified y that of the absorbents. 3. We find occasionally some portion of the cartilage covering the articular extremity of a bone altered from its natural organization, converted into a number of ligamentous fibres, each of which • • 36 OBSERVATIONS ON THE is connected by one extremity to the bone, while the other is loose towards the cavity of the joint. Here is a morbid alteration of structure, the occur- rence of which seems to indicate that there must be such a vascular appara- tus entering into the formation of cartilage as enables new materials to be deposited, and old materials to be absorded, and without which morbid altera- tions of structure do not take place in other parts of the body. In some of the cases related in the former chapters, the cartilage covering the articular cartilage had been removed for some extent on the surface towards the cavity of the joint, while that portion of it which was connected to the bone remained entire, and retained its natural structure. In the two following cases, the same thing was observed to a very great extent; and this superficial abrasion had taken place in many parts in which cartilage was in contact with cartilage, and where, therefore, it was impossible to attribute it to the operation of vessels belonging to any of the neighboring textures. Case XXVL—A boy, twelve years of age, on the 28th of .'une, 1809, fell from a height, and pitched on one of his knees. When he was brought to the hospital, he was found to have a compound fracture of the femur. For some days he appeared to go on well; but afterwards an abscess formed in the thigh, extending as high as the nates ; and he sunk and died on the 21st of July. On examining the knee-joint after death, the cartilage covering the condyles of the femur, and that covering the head of the tibia, were found, in some parts, entirely absorbed, so that the bone was exposed ; and in other parts it was absorbed on the surface towards the cavity of the joint, while the layer of it next to the bone retained its natural adhesion, and its natural structure. The cartilage, in these parts, was formed into grooves, having an appearance as if the greater portion of its substance had been removed with a chisel. There was no purulent, nor other effusion, into the cavity of the joint. Case XXVII.—A middle-aged man met with an injury of the knee, which was followed by inflammation and suppuration, and he died in St. George's Hospital on the 30th of August, 1809. On examining the joint after death, the cartilage covering the condyles of the femur, and the head of the tibia, was found entirely destroyed towards the circumference, so that the bone was exposed. Elsewhere, only a thin layer of cartilage remained ; but this had its ordinary texture, and adhered as firmly as usual to the bone. I conceive that the foregoing cases, and the other facts which have been stated, are sufficient to prove that the articular cartilages may be absorbed or ulcerated from the action of their own vessels, and that the ulce- ration may begin, and frequently does begin, on that surface which is towards the articular cavity. At the same time, it is to be observed, that in many instances the ulceration begins in another situation ; and I have frequently seen the cartilage abraded where it had been in contact with the bone; while on the surface, towards the cavity of the joint, it remained smooth and perfect. Under these circumstances, the space formed by the absorption of the cartilage becomes filled up by a vascular substance, re- sembling granulations, and uniting the bone and cartilage to each other. In whatever way the ulceration of the articular cartilage is produced, there is this remarkable difference between it and the ulceration of soft parts: suppuration seldom takes place while the ulcer of the cartilage is small; and often the disease proceeds so far as to cause caries of the bones to a great extent, without matter being formed in the joint. This circumstance is deserv- ing of notice. It has long been established, that suppuration may take place DISEASES OF THE JOINTS. 37 without ulceration; and it appears that in this instance ulceration occurs without the formation of pus. Ulceration of the articular cartilages may arise from various causes, the principal of which are as follows:— 1st, It may be the consequence of disease originating in the neigh- boring soft parts, especially of inflammation of the synovial membrane; examples of which will be found among the cases related in the pre- ceding chapters. 2dly, It may depend on a morbid condition of the cartilage itself; or, 3dly, On a chronic inflammation of the surface or substance of the bone with which it is connected. 4thly, It may be the result of a peculiar alteration in the condition of the can- cellous structure of the bones, which is met with in young scrophulous persons. This last form of the disease requires to be considered separately, and will constitute the subject of the next chapter. The observations which I have to offer at present will relate to ulceration of the cartilages occurring under other circumstances, but especially to those cases in which the disease has originated, either in the cartilage itself, or in the surface of bone with which it is connected. Case XXVIII.—In examining a body brought into the dissecting-room in Windmill-street, I found the cartilage in a diseased state, in the joints of both hips, of one of the knees, and of both elbows. In some spots, the carti- lages of these joints were altogether destroyed by ulceration, and carious sur- faces of bone were exposed; in others, the cartilage was not completely absorbed, but it had the appearance of fibres, which were connected at one extremity to the bone, while the other extremity was loose towards the cavity of the joint, and having no lateral connection with each other. The inter- vertebral cartilages connecting the bodies of some of the dorsal vertebrae were also in a diseased state. They retained the usual appearance of concentric layers towards the circumference ; but in the centre, instead of the white semi-fluid substance, which is met with under ordinary circumstances, they were found to be of a brown color, of a solid and somewhat brittle texture, composed of several portions, having a very slight adhesion to each other. The ligaments, the synovial membranes, and the bones, were all in a natural Btate, except that the latter were occasionally carious, in consequence of the absorption of the cartilage; but the caries was unattended by the formation of matter. In this case, the original disease appears to have been a morbid state, and subsequent ulceration of the cartilages. It shows that where the disposition to it exists, the destruction of the cartilage may take place in several joints at the same time; and I have observed the same thing in other instances. The conversion of the cartilage into a soft fibrous structure has been already noticed. I am disposed to believe that it is the frequent, though not the con- stant, forerunner of ulceration. In a woman, who died a week after a severe contusion of the hip, the cartilage of the head of the femur was found in some parts entirely absorbed, in others having a fibrous appearance, similar to what has been described; and I have noticed the same circumstances in other cases, sometimes connected with, and sometimes independent of local injury. Case XXIX.—A girl, seven years of age, was admitted into St. George's Hospital, in May, 1809, on account of a complaint in the left hip. She had pain in the knee, the limb was shorter than is natural, and the nates were wasted and flattened. An issue was made with caustic, behind the great trochanter. Soon after her admission an abscess burst near the crista of the « * 38 OBSERVATIONS ON THE ilium. The disease in the hip appeared to be considerably relieved ; but, on the 1st of August, she died of an accidental attack of erysipelas. On inspecting the body, the glutaei muscles of the left side were found wasted, and of a dark color. A sinus extended from the external orifice of the abscess through the soft parts, and communicated with the hip-joint, by an ulcerated opening in the margin of the acetabulum. There were no remains of cartilage on the surface of the acetabulum. The exposed bone was in a carious state, and of a dark color, and the cavity of the acetabulum was rendered deeper and wider than is usual. The greater part of the cartilage was destroyed on the head of the femur, and the small portion of it which remained was readily separated from the bone. This circumstance is often met with, where cartilage is undergoing the process of ulceration. The capsular ligament was somewhat thicker than under natural circum- stances, and more connected with the surrounding parts. There were no remains of the round ligament. In the anterior part of the joint, a quantity of organised soft substance, re- sembling that of adhesions, was interposed between the head of the femur and the acetabulum, and behind this was a collection of dark-colored pus. From these two causes the head of the femur had been separated from the os in- nominatum, and pushed outwards, and it had afterwards been drawn upwards by the action of the muscles, so that it was lodged on the superior part of the bony margin of the acetabulum. The synovial membrane was of a dark color, but not otherwise diseased. On examining the hip of the opposite side, I found the soft parts external to it, the capsular ligament, synovial membrane, and fatty substance of the joint, having no appearance of disease. The cavity of the joint contained about a dram of dark-colored pus. The cartilage was absorbed from about one third of the surface of the acetabulum. The exposed bone in most parts presented an uniform compact surface, but in two places it was in a state of superficial caries. In some parts of the head of the femur, the cartilage had a fibrous appearance, similar to what has been already described; in other parts it was entirely absorbed, and a carious surface of bone was exposed; and elsewhere it was in a natural state. The round ligament was ruptured by a very slight degree of force, which seemed to arise from the cartilage hav- ing been destroyed round its insertion into the acetabulum. The bones in the neighborhood of the carious surfaces of the left hip were of a darker color than usual; but no such appearance was observed in the bones of the other hip, which were in all respects in a healthy state. Case XXX.—John Catnack, forty-four years of age, was admitted into St. George's Hospital on the 29th of September, 1813, with pains in the lower limb of the right side, extending from the hip to the knee, and resembling the pains of rheumatism. He attributed these pains to his having caught cold about a month before his admission. He labored also under a complaint of his bowels, of which he died on the 4th of December. On dissection, no preter- natural appearances were discovered, except in the right hip. The capsular ligament and# synovial membrane were in a natural state. The cartilages covering the head of the femur, and lining the bottom of the acetabulum, were destroyed by ulceration, for about one half of their extent, and wherever the cartilage was destroyed, an ulcerated surface of bone was exposed. The round ligament was readily torn in consequence of ulceration having extended to it at the part where it was inserted into the acetabulum. The bones pos- sessed their natural texture and hardness. There was no pus in the joint. It # DISEASES OF THE JOINTS. 39 was observed, that the ulcerated surface of the acetabulum corresponded to that of the femur, these surfaces being exactly in contact, in the position in which the patient had remained since his admission into the hospital. Case XXXI.—William Bridges, twenty-one years of age, was admitted into St. George's Hospital, on the 28th of November, 1810. He gave the following account of his complaint:—About the middle of the May preceding, he first experienced a pain in the right knee, which was aggravated by walk- ing. At the end of a month, the pain became so severe that he was under the necessity of being confined to his bed. He had slight pain in the hip; but that in the knee was intense, keeping him awake at night. An abscess formed, which, in the September following, burst on the inside of the thigh. At the time of his admission, the nates were wasted and flattened; the limb on the affected side appeared to be an inch and a half longer than the other; there was a large abscess in the posterior part of the thigh. He was ema- ciated, and labored under a hectic fever. An issue was made with caustic, behind the great trochanter of the femur, and afterwards a second issue was made in the same manner on the anterior edge of the tensor vagina femoris muscle. Under this treatment, he experienced for a time great relief, notwithstanding several abscesses formed and burst in different parts of the thigh. He became free from pain; regained his flesh; the hectic fever abated, and the discharge from the abscesses was much lessened. The limb now ap- peared to be shorter than the other. He continued to mend till the middle of February, 1811. At this period the former bad symptoms began to return. He was affected with a constant diarrhoea, and profuse perspirations, and he died on the 26th of March following. On inspecting the body, the glutcei muscles were found wasted and shrunk, and in many parts their texture was destroyed by the abscesses, which com- municated with the cavity of the joint by two ulcerated openings, one on the anterior and the other on the posterior part. The abscesses formed several sinuses in the neighborhood of the joint, and the capsular ligament was in con- sequence connected to, and in some measure blended with, the other soft parts. The joint contained purulent matter. The synovial membrane was darker than natural, but otherwise had the ordinary appearance. There were no re- mains of the round ligament. The cartilages were everywhere absorbed, and the exposed surfaces of bone were in a carious state. The head of the femur was reduced to about two thirds of its original size; and the acetabulum was rendered deeper and wider, nearly in the same proportion. At the bottom of the acetabulum there was an ulcerated opening, just large enough to admit a common probe, communicating with an abscess within the pelvis. The cari- ous surfaces of the bones had the same dark color and fetid smell as in other cases of caries ; but otherwise they did not differ from healthy bones. Case XXXII.—Jemima Holloway, about twenty-three years of age, was admitted into St. George's Hospital on the 30th of March, 1814, on account of a disease of the right hip. There was a large abscess in the neighborhood of the hip, and the nates were wasted and flattened. She said that the dis- ease had been going on for some years. On the 6th of June following her admission, she died. On dissection, the glutei muscles were found wasted and flabby, and of a pale color. , There was a large abscess of the nates communicating with the hip, by .means of an opening in the posterior part of the capsular ligament and syno- vial membrane. In other respects the synovial membrane and cupsular liga- ment were in a perfectly natural state. * w OBSERVATIONS ON THE The cartilages covering the head of the femur and lining the bottom of the acetabulum were destroyed by ulceration. The ulceration had extended to the bones, so that the head of the femur was not more than half, and the ace- tabulum was double, the usual size. The bones possessed their natural tex- ture and hardness. There was an ulcerated opening at the bottom of the acetabulum, communicating with the inside of the pelvis. Case XXXIII.—Phcebe Harper, twenty-four years of age, was admitted into St. George's Hospital on the 29th of August, 1825. About two months previous to her admission she had been seized, while employed in hay-making, with an excruciating pain in the lower limb of the left side. It subsided sufficiently to allow her to walk home, but on the following day it returned, and it was now referred particularly to the groin. Leeches, blis- ters, &c. were applied, but the pain continued very severe. At the time of her being admitted into the hospital she was unable to move the limb: the foot was turned outwards; and every attempt to press the head of the femur against the surface of the acetabulum, as well as all pressure in the neighborhood of the hip-joint, occasioned violent pain, so as to make the patient scream. The whole limb was hotter than natural; pulse between 90 and 100. Altogether the disturbance of the constitution was greater than might be expected from such a local complaint. October 24th, the patient died. On dissection, it was found that no effusion, either of serum, or lymph, or pus, had taken place into the cavity of the hip joint. The synovial membrane was somewhat more vascular than usual, but the increased vascularity seemed scarcely to amount to inflammation. The car- tilage covering the head of the femur had been destroyed by ulceration for more than half its extent; so as to expose the cancellous structure of the bone. The remaining portion of the cartilage covering the head of the femur was thinner than natural: but this was more observable in some parts than in others. Every where the loss of substance appeared to be on the surface to- wards the cavity of the joint; the layer of cartilage towards the bone being unaltered, except in one spot, where it was ulcerated to a very small extent. The cartilage of the acetabulum was entirely destroyed, so that every where a carious surface of bone was exposed. There were no remains of the round ligament. The synovial membrane on one part of the neck of the femur was destroyed by ulceration; and here also a carious surface of bone was exposed. The bones themselves had their natural structure and hardness, not differing from healthy bones, except on the carious or ulcerated surfaces. I could add to the foregoing an account of the dissection of several other cases, in which the hip was affected with the same disease; but, in doing so, I should only occupy the reader's attention unnecessarily. It will be suffi- cient to observe that,— 1. In the most advanced stage of the disease, none of the parts entering into the composition of the joint retain their natural structure. The soft parts are blended into a confused mass. Sometimes the head of the femur is completely destroyed, and there remams only the neck, or a portion of the neck, of that bone. Often the projecting margin of the acetabulum is entirely absorbed; so that, instead of a cavity, there is a broad carious surface of the os innominatum. In a few instances, a portion of the carious bone is found dead, and undergoing the process of exfoliation, or having already exfoliated into the cavity of the joint • DISEASES OF THE JOINTS. 41 2. In whatever period of the disease the examination is made, the cartilages are found in a state of ulceration; but the morbid affections of the soft parts and bones vary very much: nor are they much altered from their natural state, except in the most advanced stage of the malady. From these circumstances, and from the appearances in several of the cases which have been related, in which the disease was found in its incipient stage, and wholly confined to the cartilages and bony surfaces with which the cartilages are in contact, we may conclude that, in a large proportion of cases of caries of the hip, these are the parts primarily affected, and the following may be stated to be the progress of the disease:— 1. Ulceration takes place in the cartilages; generally in that of the aceta- bulum first, and in that of the head of the femur afterwards: sometimes it begins in both at the same time. 2. The ulceration extends to the bones, which become carious; the head of the femur is diminished in size, and the acetabulum is rendered deeper and wider. 3. Abscess forms in the joint; which after some time makes its way. by ulceration, through the synovial membrane and capsular ligament, into the thigh or nates, or even through the bottom of the acetabulum, into the pelvis. Sir Astley Cooper has shown me two specimens, in each of which an abscess connected with a diseased hip had burst into the rectum. 4. In consequence of the abscess, the synovial membrane and capsular ligament become inflamed and thickened. The muscles are altered in struc- ture ; sinuses are formed in various parts ; and, at last, all the soft parts are blended together into one confused mass, resembling the parietes of an or- dinary abscess. In giving this statement, it is not my intention to assert that the hip is not liable to other morbid affections. I have in a former part of this work de- scribed the symptoms produced by inflammation of the synovial membrane of this joint. In the next chapter I shall point out another order of cases, in which the hip is affected in consequence of a scrophulous disease originat- ing in the bones themselves: but still the conclusion remains that, in a great, and, I believe, in the greater, number of those cases to which the name of "diseased hip" has been usually applied, the ulceration of the cartilages is the primary affection, and the other parts in and near the joint become affected only in a secondary manner. As, from the peculiar situation and connections of the hip, diseases of this part are attended with particularly serious consequences, I trust that the foregoing account will not be considered as given too much in detail, espe- cially as it will prevent the necessity of entering with much minuteness into the history of the ulceration of the cartilages of other joints, in which the progress of the disease, allowance being made for the difference of structure and situation, is the same as in the hip. Case XXXIV.—David Martin, twenty-six years of age, was admitted into St. George's Hospital, on the 25th of July, 1810, on account of a dis- ease in his right knee. He attributed it to a blow, which he had received some years previous; but he said, that the symptoms had all been much ag- gravated within the last six months. At the time of his admission into the hospital, the knee had the appearance of being swollen; but, on examina- tion, this was found to arise from the wasting of the muscles, rather than from actual enlargement. The leg was fixed, or nearly so, in the half-bent position. The condyles of the femur projected beyond the head of the tibia. He complained of pain, which was particularly severe at night. An issue 42 OBSERVATIONS ON THE was made with caustic on each side of the patella j but the symptoms were not relieved, and an abscess burst on the outside of the joint, discharging a large quantity of matter. t Soon after his admission, he experienced, for the first time, severe pain in the other knee; but this was unattended by swelling, or any alteration in the form of the joint, and the leg admitted of complete extension and flexion on the thigh. The pain continued, but no swelling ever took place. In the beginning of September, he was seized with an accidental attack of erysipelas. Abscesses formed in different parts of the leg and thigh; and he gradually sunk, and died on the 7th of November. On inspecting the body, the right leg was found bent so as to form a right angle with the thigh. The head of the tibia had been drawn towards the ham by the action of the flexor muscles, so that the condyles of the femur were unusually protuberant. The lateral ligaments were in a natural state. There were no remains of the crucial ligaments, or semi-lunar cartilages. The cartilages of the tibia, femur, and patella had been entirely absorbed. The bones were carious on their exposed surfaces, but not otherwise dis- eased. The synovial membrane was free from all morbid appearances, ex- cept at the points of its attachment to the bones; where, in a few places, coagulated lymph had been effused on its surface. The left knee, externally, had its natural appearance with respect both to form and size. The leg admitted of complete flexion and extension. On dissection, the ligaments and synovial membrane were found in a perfectly healthy state ; but about one third of the cartilaginous surfaces of the tibia and femur was destroyed by ulceration, the ulceration having taken place principally, but not entirely, near the circumference. The cartilage of the patella and the semi-lunar cartilages were entire; but the latter in some parts, were softer than usual. The bones were free from disease. There was no pus or other fluid in the joint. The dissection of this case, in which the ulceration of the cartilaginous surfaces was evidently the primary disease, explains well the nature of, at least, many cases of that species of white-swelling, which some authors have described; in which there is long-continued and severe pain in the joint, be- fore any tumor is observable. Case XXXV.—William Bowles, eighteen years of age, was admitted into St. George's Hospital, on the 1st of December, 1810. He said that, about eleven months previous to his admissi»n, he had been seized with pain in his right knee, which was so severe as to keep him frequently awake at night. Six weeks after the pain attacked him, the joint for the first time became swollen. He now applied to a practitioner; under whose treatment, joined with perfect rest, the pain and swelling subsided, so that he was able to walk about. In the September following, having returned to his usual occupations, and used the joint a good deal, the pain and swelling returned. At the time of his admission, the affected knee was about an inch and a half in circumference larger than the other. The swelling ltad the form of the articulating ends of the bones. The leg was half bent, and all attempts to give it motion gave great uneasiness. The pain which he experienced was great at all times, but particularly at night, when it very much disturbed his rest. f Soon after his admission, an abscess was discovered on the outside of the knee, which burst in the beginning of February, and discharged a large quan- tity of matter. On the 18th of March, the limb was removed by amputation. On examining the joint the greater part of the cartilaginous surfaces of the ft DISEASES OF THE JOINTS. 43 tibia, femur, and patella were found destroyed by ulceration. Where the cartilage was destroyed, the exposed bone was carious, and in some places covered by a thin layer of coagulated lymph ; but in other respects the bone was free from disease. There were scarcely any remains of the semi-lunar • cartilages. The joint contained pus, and the abscess in the joint had made its way into the external parts, through an ulcerated opening in the synovial membrane. The synovial membrane was in a natural state, except that, in a few places, there was a thin layer of coagulated lymph on its surface, which evidently had been recently effused. The external lateral ligament was de- stroyed by the abscess ; the other ligaments were entire. In this case, the principal disease observed in the dissection, was the ulcerated state of the cartilages. There was no affection of the synovial membrane beyond what might be considered as arising from the formation of pus in the joint, and the bursting of the abscess externally. Where inflam- mation of this membrane is the primary disease, swelling takes place often in a few hours, always within two or three days from the beginning of the attack ; whereas in this instance, the constant answer which the patient gave to the repeated inquiries made of him, was, that he had had violent pain for six weeks before the joint was observed to be enlarged. From all these circum- stances, we may conclude that, in this case, as well as in the last, the carti- lages were the original seat of the disease, and that the morbid appearances observed in the soft parts were the consequence of the formation of the abscess in the joint. The same conclusion may be drawn respecting the cases which follow. Case XXXVI.—Mary Anderson, twenty-eight years of age, was admitted into St. George's Hospital, on the 6th of April, 1815. At this time, she complained of intense pain in the right knee, which was particularly severe at night, so as exceedingly to interrupt her rest. The pain was referred principally to the head of the tibia. There was a slight swelling of the joint, having the form of the articulating ends of the bones, and not giving to the hand the smallest sense of fluctuation. The leg admitted of being moved on the thigh, but all motion aggravated the pain. No more particular account of the previous history of the case could be procured than the following:—that she had labored under pains of the right knee for nearly six years which had been occasionally relieved ; and that, in the first instance, the pain had been unattended by swelling. Immediately on her admission, an issue was made with caustic, on each side of the patella. On the 9th of April the pain had very much abated. The issues were kept open by the occasional application of caustic; and the pains very soon left her, and the swelling diminished. About the 8th of June, she began to experience a return of the pains in the knee, and in the course of four or five days they were so severe as to keep her awake at night. There were convulsive startings of the limb, and the joint was swollen in a greater degree than formerly. The pains increased in violence, and her health began to suffer considerably. On the 3d of July the limb was amputated. On examining the knee, some lymph and serum were found effused into the cellular membrane external to it. The cavity of the joint contained Ibout half an ounce of thin purulent fluid; the cartilage covering the patella was, in some parts, in a natural state; in others, it had the fibrous structure, which I have described in a former part of this chapter; and, in others, it was completely destroyed by ulceration, so as to expose the surface of the bone. The cartilage covering the articula- 44 OBSERVATIONS ON THE ting extremity of the femur presented the same variety of appearances. On the inside there was a spot of some extent, which, instead of cartilage, was covered by a kind of membrane, resembling the substance of adhesions, but somewhat more dense in its structure; as if the cartilage had been formerly destroyed at this part, and coagulated lymph had been effused on the ulcera- ted surface of bone, which had afterwards become organized. The cartilages of the tibia were ulcerated for a very small extent. The synovial membrane in general was in a natural state. In some places it was slightly inflamed. On the outside of the joint, it was inflamed in a greater degree than elsewhere, and thickened, and had begun to ulcer- ate evidently in consequence of the abscess in the joint having begun to make its way to the external surface. The bones possessed their natural texture and hardness. Case XXXVII.—Jane Bannister, forty years of age, was admitted into St. George's Hospital, in September, 1810, on account of a disease in her right foot. She gave the following account of her case:— In the September of the preceding year she wrenched her instep, and soon afterwards experienced violent pain in this part, so that she was una- ble to stand on that foot, and her rest was much disturbed at night. The pain continued very severe, and, at the end of four months she observed, for the first time, a slight swelling on the inside of the foot. This was occa- sioned by an abscess, which was opened by her medical attendant in the April following. At the time of her admission into the hospital the whole foot was swollen, and she complained of violent pain in it. The abscess continued open, dis- charging a small quantity of pus. On introducing a probe into the orifice, an exposed surface of bone was felt. Several applications were made with- out benefit, and the leg was amputated on the 25th of February, 1811. On examining the amputated foot the cartilages of the joint formed by the astragalus and os navicular were found destroyed by ulceration, and a portion of the astragalus was dead, and undergoing the process of exfolia- tion. The cartilages of the joints formed by the cuneiform bones with each other, with the os naviculare, and with the metatarsal bones, were in like manner destroyed, and the exposed surface of bone were carious. The abscess communicated with the carious joints. The ligaments and synovial membrane were in a natural state, except in a few spots, where they were destroyed by the abscess. The bones possessed their natural texture and hardness. The cellular membrane of the foot contained coagulated lymph and serum. Case XXXVIII.—Thomas Herbert, fifty-eight years of age, was admitted into St. George's Hospital on the 14th of September 1825. He complained of pain and tenderness of the left knee. The leg was kept in the half-bent posture ; and there was a severe aggravation of the pain on every attempt to move it. There was a slight swelling of the joint, not arising from fluid collected in its cavity, but from an effusion into the cellular texture external to it. The man was in ill-health, and his memory was im- paired, so that no history of his case could be procured. Blisters were applied and kept open ; but notwithstanding these remedies joined with a state of complete repose, an abscess presented itself on the out- side of the joint, and burst, discharging a large quantity of pus. It now be- came a question whether the limb should not be removed by amputation; but an attack of erysipelas prevented the operation. The patient gradually be- came more exhausted, and died in the beginning of December. DISEASES OF THE JOINTS. 45 On dissection, the cartilage of the patella of the left knee was found in some parts destroyed, so as to expose the surface of the bone ; while in other parts it had lost its natural structure, and was converted into a fibrous substance. The cartilages of the head of the tibia and condyles of the femur, were al- most every where destroyed, so that extensive surfaces of carious bone were exposed. The abscess did not communicate with the general cavity of the joint, but i.as limited to the portion of it formed by the external cor.'yV of the femur and the external articulating surface of the tibia ; and here the cancellous structure of the bones adjoining the ulcerated surfaces was of a dark color. Everywhere else the bones belonging to the diseased joint retained their natu- ral texture and hardness. In the right knee, which had been supposed, while the patient lived, to be free from disease, the cartilage of the patella had, in some parts, entirely dis- appeared, so that the bone had become exposed; in other parts,it was con- verted into a fibrous substance; and in other parts, it retained its natural structure and appearance. The cartilages of the femur and tibia of the right knee were somewhat thin- ner than natural, and of a yellowish-white color ; but they were entire, except on the edge of one of the condyles of the femur, where the cartilage was in a state of incipient ulceration, and the surface of the bone was of a red color in a spot about one third of an inch in diameter. The synovial mem- brane was in a natural state. The following case affords an example of ulceration of the articular cartila- ges occurring as a secondary disease, the primary disease having had the character of a rheumatic inflammation of the bone and periosteum. I have seen a few other cases apparently similar to this, but in which no opportunity occurred of ascertaining the exact nature of the disease by dissection. The history of one of these will be found among the cases related hereafter. Case XXXIX.—Sarah Holder, twenty-two years of age, was admitted into St. George's Hospital, on the 26th of July, 1827, with a diffused swelling extending from the upper part of the right thigh to the leg, a little below the knee. The swelling was most conspicuous in the immediate neighborhood of the knee-joint; and from thence gradually became diminished, having no de- fined termination either above or below. It was somewhat elastic, the skin over it appearing glossy and tense, but not redder than natural. The patient complained of exquisite pain, especially on pressure. The pain was also aggravated by every motion of the knee; nevertheless it was principally re- ferred, not to the joint itself, but to the thigh-bone immediately above it. In addition to these local symptoms, the pulse was frequent; the tongue furred, and rather brown ; the skin hot; and the countenance anxious and expressive of much suffering. The condition of the patient was altogether a good deal similar to that which might be produced by severe rheumatic inflammation of the bone and periosteum; and the history of the case seemed to justify the opinion that such was the nature of the disease, as the symptoms had begun without any precursory rigor on the day previous to her admission, and had beoii pi weeded, for an entire month, by rheumatic pains in the elbows and shoulders. t Saline and antimonial medicineswere exhibited; leeches were freely ap- plied to the limb, and on the 28th of July, a pill, containing two grains of calomel and half a grain of opium, was exhibited twice daily. Under this treatment the gums became slightly affected, and the symptoms gradually abated. On the 3d of August, the mercurial pill was given only once daily ; 46 OBSERVATIONS ON THE and, in the course of a few days more, it was altogether discontinued, blisters being at the same time applied to the limb. August 13. The swelling and pain had entirely left the upper part of the thigh; but there were still some remains of both in the immediate neighbor- hood of the knee. Altogether, she was in a much better state with respect to the local symptoms, and the general health was improving. August 15. After an accidental exposure to cold, she had a rigor, followed by fever; and, at the same time, there was a recurrence of pain and swelling in the neighborhood of the right knee, with some degree of pain and tender- ness extending up the thigh, and down the leg. The swelling had the same character as formerly. August 20. She continued in nearly the same state, with painful start - ings of the limb, and perspirations at night. Pulse very frequent. She was directed to resume the use of calomel and opium. Sept. 2. There was no material improvement as to the local symptoms : a blister was applied to the knee. She continued in nearly the same state, sometimes a little better, some- times a little worse, with a very frequent pulse, and the general health, on the whole, declining, until the 7th of October; when an issue was made with caustic in the neighborhood of the knee. The issue seemed to occasion some abatement of the local symptoms. Her bodily powers, however, con- tinued to decline, and she became effected with an ulcer over the sacrum, the result of long-continued pressure. Oct. 14. She complained of severe pain in the left shoulder. Oct. 15. She was seized with a vomiting and purging, accompanied with pain and tenderness of the abdomen and cold extremities. Pulse 140. At midnight she had a severe rigor. The vomiting and purging continued, in spite of the remedies which were employed. In the afternoon of October 16, she had another rigor, and in about two hours.afterwards she expired. On examining the body, the knee-joint was found to contain neither pus nor synovia. The cartilage of all the bones which enter into the composi- tion of the joint were ulcerated in several places, especially that of the inner condyle of the femur. A slight extravasation of blood had taken place into the cavity of the joint apparently from the surfaces of the bone exposed in consequence of the ulceration of the cartilages. The periosteum could be easily peeled off the surface of the femur, and the bone underneath appeared to be more vascular than is natural. The stomach was distended with an acid fluid of a green color, similar to what had been vomited on the day preceding death. The gall bladder was full of a very pale yellow fluid. There were no other morbid appearances. The left shoulder, to which pain had been referred for a short time previ- ous to death, was carefully examined, but no disease was detected in it. It would be needless to add to the foregoing list an account of other cases, in which the disease was in a still more advanced stage. The progress of it in other joints, corresponds with that in the hip; and whatever may be the joint affected, there is ultimately the same complete destruction of the carti- lages, and the same extensive ravages are committed among the bones and soft parts. DISEASES OF THE JOINTS. 47 SECTION" II. On the Symptoms of this Disease. The ulceration of the articular cartilages may occur at any period of life; but it is most frequent in those who have passed the age of puberty, and who are under thirty or thirty-five years of age. We meet with it, however, some- times in young children, and at other times in old persons. In general, the disease is confined to a single joint; but occasionally two or three joints are affected in the same individual, either at the same time or in succession. Some- times the patient traces the beginning of his symptoms to a local injury ; but for the most part no cause can be assigned for the complaint, and often the cause to which it is attributed appears to be imaginary rather than real. It is this disease which forms the great majority of those cases of caries of the hip-joint which occur in adult persons ; whereas, in children, the hip-joint is principally affected by that scrophulous disease affecting the cancellous structure of the bones, which will be described hereafter. These two classes of cases have many circumstances in common ; and as I shall, in the present chapter enter into a minute history of the progress of the former, I shall be enabled, in the next chapter, to confine my observations respecting the latter chiefly to those points of difference on which our diagnosis, so far as it can be made, must mainly depend. Where the cartilages of the hip are ulcerated, as a consequence of inflam- mation of the synovial membrane, the peculiar symptoms which it presents are preceded by those of the last mentioned disease: otherwise, the only symptoms met with, for some time, are pain, and a slight degree of lameness in the lower limb. The pain at first is trifling, and only occasional; after- wards becoming severe and constant. It resembles a good deal the pain of rheumatism, since it often has no certain seat; but is referred to different parts of the limb in different individuals, and even in the same individual at different periods. As the disease advances, the pain becomes exceed- ingly severe, particularly at night, when the patient is continually roused from his sleep by painful startings of the limb. Sometimes he experien- ces some degree of relief from the pain in a particular position of the joint, and in no other. A patient in St. George's Hospital never obtained any rest, except when he had placed himself on the edge of the bedstead, with his feet on the ground, and resting his body on a pillow, in a position be- tween that of lying and sitting. Another patient was seen night and day, crouching on his knees and elbows. As the pain increases in intensity, it is more confined in its situation. In the greater number of instances, it is referred to the hip and the knee also ; and the pain in the knee is generally the most severe of the two. At other times there is pain in the knee, and none in the hip. Sometimes there is pain referred to the inside of the thigh; or even to the foot. Wherever the pain is situated, it is aggravated by the motion of the joint; but it is aggravated in a still greater degree by whatever occasions pressure of the ulcerated carti- laginous surfaces against each other. Hence the patient is unable to support the weight of the body on the affected limb ; and if he be placed on an even surface°in a horizontal position, and the hand of the surgeon be applied to the heel, so as to press the head of the femur against the concavity of the aceta- 48 OBSERVATIONS ON THE bulum, violent pain is the consequence; although this be done in so careful a manner that not the smallest degree of motion is given to the hip-joint. This circumstance is well deserving of attention ; and no one should attempt to give an opinion as to the nature of a disease connected with the hip, with- out having made an examination in the manner which has been just described. Soon after the commencement of the complaint, the hip-joint is found to be tender, whenever pressure is made on it, either before or behind. The absorbent glands in the groin become enlarged, and sometimes suppurate. Occasionally there is a slight degree, of general tumefaction in the groin. In this there is nothing remarkable, since we must suppose, that a disease going on within the articulation must ultimately occasion some degree of inflamma- tion in the neighboring parts. But it is a curious circumstance, that in some cases there is tenderness of those parts to which, though not diseased them- selves, the pain is referred from sympathy with the disease in the hip. I have observed this in the knee several times ; and I have also seen a slight degree of puffy swelling of this joint, where pain was referred to it, in consequence of disease in the hip. These facts correspond to what may be observed in some other cases, where pain is referred to a sound part, in consequence of a sympathy existing between it and some other part that labors under disease: for example, I have known the passage of a calculus down the ureter to oc- casion not only pain, but tenderness, swelling, and no trifling inflammation of the testicle. When the disease has existed for some time, the nates undergo a remarkable alteration in their form. They become wasted and less prominent; so that in- stead of their usual convexity, they present the appearance of a flattened sur- face ; they are flaccid to the touch, and hang more loosely towards the lower edge ; and they have the appearance of being wider than those of the other side. In a very few cases, in the advanced stage of the disease, the nates are really wider, in consequence of the acetabulum being filled with coagu- lated lymph and matter, and the head of the femur being pushed out of its natural situation. But, in general, the increased breadth of the nates is only apparent, and, on an accurate measurement, no difference will be found be- tween the nates of one side and those of the other. The alteration in the figure of the parts, in these cases, may arise partly from the position in which the patient usually places himself when he stands erect; but the principal cause to which it is to be attributed, is the wasting of the large fleshy bellies of the glutsei muscles from want of use; and this has been ascertained, by repeated and accurate examinations of the living, and numerous dissections of the dead body.* Another symptom which occurs in this disease, is an alteration in the length of the limb. 1st, In the early stage of the disease the patient often complains, that the limb on the affected side is longer than the other. This cannot be explained on the supposition of the acetabulum being filled with pus, or solid substance, since this would cause the head of the femur to be pushed outwards rather than downwards. The fact is, that there is only an apparent, and no real, elongation of the limb. If t!^ p;;i.icut be placed en his back in the. hori- * This alteration in the form of the nates is a symptom, but is not in itself to be considered as a certain diagnostic mark of disease in the hip-joint; as it may be observed in other cases. where, from any cause, the glutaei muscles have been for a considerable time in a state of in- action. Thus children are subject to a paralytic state of the muscles of the lower limb • and in this complaint, if the muscles are affected as high as the pelvis, the nates present to the eye the same appearance. It may be noticed also where there is disease of the thigh-bone, or where from any other cause, the motion of the hip is painful and difficult. DISEASES OF THE JOINTS. 49 zontal position, with the thighs parallel to each other, the foot on the diseased side may at first appear as much as two or three inches lower than the oppo- site foot; but, if the distance be accurately measured with a tape; from the anterior superior spinous process of the ilium to the patella, no difference is perceptible. The apparent elongation is produced by the position of the pelvis being altered, in such a way that the crista of one ilium is visibly de- pressed below the level of that of the other. It is easy to understand how this effect is produced, by observing the position in which the patient places himself when he stands erect. He supports the weight of his body on the sound limb ; the hip and knee of which are, in consequence, maintained in the state of extension. At the same time the opposite limb is inclined forward, and the foot on the side of the disease is placed on the ground, considerably anterior to the other ; not for the purpose of supporting the superincumbent weight, but for that of keeping the person steady, and preserving the equili- brium. Of course, this cannot be done without the pelvis on the same side being depressed. The inclination of the pelvis is necessarily attended with a lateral curvature of the spine ; and hence it happens that one shoulder is higher than the other, and that the whole figure is in some degree distorted. All these symptoms will disappear in the course of a few weeks, if the patient, under these circumstances, be confined to his bed in the supine and horizontal position ; except in some instances, where, in consequence of their having occurred in a young and growing person, and having already been allowed to exist for a considerable time, the shape of the parts has become adapted to their new situation, and the alteration of the figure may continue during life. 2. In a few cases, where the patient is in the erect position, it may be ob- served that the foot which bejongs to the affected limb is not inclined more forward than the other, but that the toes only are in contact with the ground, and the heel raised; at the same time that the hip and knee are a little bent. This answers to the patient the same purpose of enabling him to throw the weight of his body on the other foot; but it produces an inclination of the pelvis in the opposite direction. The crista of the ilium is higher than natural, and there is an apparent shortening, instead of elongation, of the limb on the side of the disease. 3. In the very advanced stage of the disease, when the head of the femur has been completely destroyed by ulceration, there is nothing to prevent the muscles from pulling the bone upwards. This may be compared to a case of fractured neck of the femur. The limb is not only apparently, but it is really, shortened ; the foot may be rotated inwards, but, if left to itself, it generally is turned outwards. 4. In other cases, the limb is shortened ; the thigh is bent forwards ; the toes are turned inwards, and do not admit of being turned outwards; and there is every symptom of a dislocation of the hip upwards and outwards. The following case fully explains the cause of these appearances. Case XL.—Taylor, a middle-aged man, was admitted into St George's Hospital in the autumn of 1805, on account of a disease in his left hip. He labored also under other complaints ; and he died in the February following. On inspecting the body, the soft parts in the neighborhood of the joint were found slightly inflamed, and coagulated lymph had been effused into the cel- lular membrane round the capsular ligament. There were no remains of the round ligament. The cartilages had been destroyed by ulceration, except in a few spots. The bones, on their exposed surfaces, were carious ; but they retained their natural form and size. The acetabulum was almost completely filled with 7 50 OBSERVATIONS ON THE pus and coagulated lymph ; the latter adhering to the carious bone, and hav- ing become highly vascular. The head of the femur was lodged on the dorsum of the ilium. The capsular ligament and synovial membrane were much dilated ; and, at the superior part, their attachment to the bone was thrust upwards, so that, although the head of the femur was no longer in the acetabulum, it was still within the cavity of the joint. Since the man did not attribute this disease to any local injury, we may conclude that the ulceration of the cartilage was the primary affection, and that the dislocation had been produced in consequence of the destruction of the round ligament, and of the head of the femur having been first pushed outwards by the coagulated lymph and pus which occupied the cavity of the joint, and then drawn upwards by tbe action of the muscles inserted into the great trochanter.* The shortening of the limb, which takes place in the advanced stage of the disease, is usually, but not always, the precursor of abscess. The forma- tion of matter is also indicated by an aggravation of the pain, by more fre- quent spasms of the muscles, by a greater wasting of the whole limb, and by the circumstance of the thigh becoming bent forward, and being incapable of extension without such an increase of the patient's sufferings as he will be unable to endure. At the same time the pulse becomes frequent, the tongue furred, and the whole system is in a state of preternatural excitement. The abscess usually shows itself in the form of a large tumor over the vastus externus muscle; sometimes on the inside of the thigh, near the middle ; and occasionally two or three abscesses appear in different parts and burst in succession. The abscesses discharge a large quantity of thin pus ; and, in the worse cases, a copious suppuration continues, until the powers of the patient are exhausted, so that, enfeebled and emaciated, he sinks under the symptoms of a hectic fever. That an adult should recover under these circumstances, is so rare an occurrence, that the surgeon can never be jus- tified in giving any but the most unfavorable prognosis. Children recover more frequently in this advanced stage of the disease ; but seldom without a complete anchylosis of the joint. If suppuration has not taken place, it generally, but not always, happens, that the limb, after the cure, regains its natural degree of mobility.f When the cartilages of the knee are ulcerated, there is pain in the affected joint; at first, it is slight and only occasional, and, in the early stage of the disease, it is completely relieved by remaining in a state of rest for a few days; but it returns as soon as the patient resumes the exercise of the limb. By degrees the pain becomes constant and very severe, particularly at night, when it disturbs the patient by continually rousing him from his sleep. The pain is referred principally to the inside of the head of the tibia; but some- * This case affords one example of the dislocation of the hip from an internal cause, which some surgical writers have described. Other examples of this kind of dislocation occur in cases of inflammation of the synovial membrane, as has been explained in a former chapter. t The morbid affections of the hip most liable to be confounded with that which has been above described, are the following:— 1. Inflammation of the synovial membrane. 2. The scrophulous disease, having its origin in the bones of which I shall speak hereafter. _ 3. A painful nervous affection, which occurs chiefly in young females disposed to hyste- ria ; which will also be noticed in a subsequent chapter. 4. Affections of the sciatic nerve, of the upper part of the femur, and other diseases external to the hip are not unfrequently mistaken for disease in the joint itself, especially by surgeons of limited experience, who are misled by the wasting of the glutcei muscles, and the flattened appearance of the nates, which may occur in any one of these cases. DISEASES OF THE JOINTS. 51 times a slighter degree of pain extends down the whole of that bone. The pain is aggravated by motion, so that the patient keeps the limb constantly in one position, and generally half bent; and he never attempts to support the weight of the body on the foot i -f this side. The ulceration of the carti s of the knee differs, with respect to its symptoms, from inflammation synovial membrane, in this,—that the pain in the former is slight in tne beginning, and gradually becomes very in- tense, which is the very reverse of what happens in the latter. But there is another circumstance, which forms a remarkable distinction between the ulce- ration of the cartilages, and most other diseases to which this joint is liable. The pain, in the first instance, is unattended by any evident swelling ; which comes on never in less than four or five weeks, and often not until several months have elapsed from the commencement of the disease. The reason of this is too manifest to require explanation, and it is equally unnecessary to point out the importance of it, as affording the means of making a more ready diagnosis. We must, not, indeed, conclude indiscriminately, whenever there is a slight pain in the knee, unattended by swelling, that the cartilages are in a state of ulceration, since this symptom may equally arise from inflammation of the bones themselves ; of the ligaments; of the fatty substance of the joint; or from simple nervous affection; and instances will occur to every surgeon, where there is reason to believe that the above-mentioned symptom arises from one or other of these causes. But when the pain continues to increase, and at last becomes very severe ; when it is aggravated by the motion of the ioint and by the pressure of the articulating surfaces against each other; and when, after a time, a slight tumefaction takes place, such as I shall presently describe ; we may conclude that the disease consists in an ulceration of the cartilages; and, in all such cases which have come under my own observa- tion, their subsequent progress, and the morbid appearances presented by dissection, where an opportunity has occurred of observing them, have fully justified this conclusion. , The swelling which attends this disease, m the knee, differs from that which occurs in either of those diseases of the synovial membrane which I have form- erly described. It arises from a slight degree of inflammation having taken place in the cellular membrane external to the joint, m consequence of the Sisease within it. The swelling is usually trifling, appearing greater than it really is, in consequence of the wasting of the muscles of the limb. It has the form of the articulating ends of the bones ; that is, the natural form of the ioint. No fluctuation is perceptible, as where the synovial membrane is in- named; nor is there the peculiar elasticity which exists where the synovial membrane has undergone a morbid alteration of structure. But a few cases oc?ur in which this disease is attended with a collection of jdul a lew cases u^ui m vrmv,.i ->"~---------- ~ fluid in the ioint, and in which, therefore, the tumor has a form different from that which has been described, and giving to the hand a distinct sense of "isT Inflammation of the synovial membrane may terminate in ulceration of the cartilages ; in which case it sometimes happens, that the flurn, secreted into the cavity of the joint, in consequence of the primary disease, is ab- sorbed ; while, in other cases, it is not absorbed before the peculiar symp- toms of the secondary disease have shown themselves ; or, 2dly. This order may be reversed ; inflammation of the synovial membrane bein.y be found to be wholly inapplicable to another. In fact, there is scarcely any disease Avhich presents itself under a greater number of forms, or in Avh'ich, in the early stages, at least, so much experience and discrimination are necessary to enable us to form a right diagnosis. In the majority of cases, the first symptom Avhich the patient notices, is pain referred to that part of the spine in which the caries exists; at first tri- fling, but becoming more severe afterwards. The pain is aggravated by any sudden motion of the spine j by percussion, or by a jar communicatee! to it * in any other Avay; as by stamping on the ground, striking the foot acciden- tally against a stone, sneezing or couglung. In the advanced stage of the disease the pain is sometimes so severe, and so easily induced, that the pa- tient cannot bear the slightest movement. Yet, in other cases, there is sometimes no pain in the spine whatever, from the first access of the disease t > its termination. I was consulted concerning a young gentleman, in whom, judging from the degree of distortion, I was satisfied that the bodies of not fewer than four or five of the dorsal vertebrae must have been Avholly de- stroyed, and that the disease had been going on for several years : yet he had never been knoAvn to complain of pain ; and the first circumstance which attracted the attention of the parents, Avas the angular projection of the spi- nous processes. This patient ultimately died, and on examining the body after death, a large abscess Avas discovered lying on the surface of the cari- ous vertebrae. In another case, in which the disease Avas supposed to have been cured, and the patient had not experienced pain for the two or three preceding years, on examining the appearances after death, I found the bodies of the vertebras still in a state of caries, and an abscess, containing not less than half a pint of matter, connected Avith them. The distortion of the spine, Avhich occurs in these cases, is of a peculiar kind. It is bent forward, so as to form an angle projecting posteriorly; and it is evident that this cannot happen Avithout the destruction of the bodies of one or more of the vertebrae. It is not less evident that the caries must have made considerable progress before this symptom shows itself; and, accordingly, Ave find that it has been preceded by pain, referred to the affected part, during a period which varies from three months to two years, and Avhich is sometimes even longer than this. I have already mentioned that there are exceptions to this general rule, but these are ot rare occurrence; and Avhere pain in the early sta"-e of the disease is wanting, there is usually some derangement of the general health, weakness of the extremities, or other symptoms, showing that the patient labors under some kind of disease, Avithout indicating its exact nature and locality. DISEASES OF THE JOINTS. 95 In general, the curvature is at first only just perceptible, and, by degrees, it becomes more distinct. In one instance, a young Avoinan, Avho had made no previous complaints, immediately after some slight exertion, experienced a sensation as if something had given Avay in her back, and immediately after- wards lost the use of her loAver limbs. This Avas followed by an angular projection of the spinous process of one of the inferior dorsal vertebrae, and a large abscess, which presented itself on one side of the abdomen; and the patient ultimately died. In another case, after the curvature had taken place, the form of it appeared to vary, in consequence of the diseased vertebrae admitting of being moved to a certain extent on each other ; these motions being attended Avith increased pain, both in the spine and in the loAver extre- mities. The last mentioned patient ultimately recovered. Curvature of the spine in the direction forwards may arise from other causes, as a weak condition of the muscles, or a rickety affection of the bones. In general, in such cases, the curvature occupies the Avhole spine, which as- sumes the form of the segment of a circle. At other times, however, it occupies only a portion of the spine, usually that Avhich is formed by the superior lum- bar ana inferior dorsal vertebrae ; as I have ascertained, not only by examin- ations during life, but by dissection after death. Here the curvature is always gradual 5 never angular; and thus it may be distinguished from the curvature arising from the caries. Nevertheless, I am satisfied that these different kinds of curvature, arising from different causes, have frequently * been confounded with each other; and that some of the cases which have been published as examples of caries of the spine, and in Avhich it may, at first, be a matter of surprise that so complete and so speedy a cure has been effec- ted, have in reality been cases of an entirely different malady.* I have already mentioned, that there is reason to believe that suppuration takes place at an earlier period in those cases in Avhich the disease has its origin in the cancellous structure of the bones, than Avhere it begins in the° intervertebral cartilages. It is remarkable, in some cases of tnis last description, to how great an extent ulceration will sometimes proceed, Avith- out the formation of abscess. I have knoAvn as many as three bodies of ver- tebrae completely destroyed, and the disease to have lasted many years, Avith- out matter having been formed ; a fortunate circumstance for the patient, as the chance of his recovery is much greater under these, than it would have been under the opposite circumstances. We must not, hoAvever, conclude, because no abscess has shoAvn itself, that therefore no abscess exists. Fre- quently, in examinations after death, Ave find an abscess in connection with carious vertebras, which had never presented itself externally, but Avhich evi- dently had existed for a considerable length of time. It is not uncommon to find caries of the vertebrae going on for two or three years before there are any certain indications of the existence of abscess. In one case, in which the disease Avas in the vertebras of the loins, an abscess presented itself in the groin at the end of eight years; and in another case, in which the disease was situated in the dorsal vertebrae, the interval was stilt longer—not less than sixteen years. The formation of abscess is usually at- tended with some derangement of the-general health, such as loss of flesh and muscular poAver; increased frequency of the pulse; a slight access of fever in the evening, followed by perspirations at night; occasionally, but rarely, rigors. * Some excellent observations on this subject ha\-e been published by Mr. Earle, in the Edinbur-y Medical Journal for January, 1315. 96 OBSERVATIONS ON THE These symptoms may be in some degree relieved by the first bursting of the abscess; but when the daily discharge of matter has continued for some time, they recur in an aggravated form: the patient wastes under the influ- ence of a hectic fever, and some kind of visceral disease supervenes, which proves the immediate cause of death. The foregoing observations relate to cases of caries of the spine generally; but, to complete the history of the disease, it is necessary to consider the pe- culiar symptoms which it produces, accordingly as one or another part of the column of the vertebrae is affected by it. When there is caries of the cervical vertebrae, the patient complains, in the first instance, of pain in the neck, Avhich is aggravated by every motion of the head, and which is not unfrequently mistaken for the muscular pains and stiffness connected with what is commonly called a stiff neck from cold. The pain gradually increases, and, according to my experience, is more liable to be severe than when the seat of the disease is in the lower part of the spine. Whenx in the progress of the disease, the spine has become incurvated for- ward, the angular projection posteriorly is observed to be trifling, except when the lowest or seventh cervical vertebra is implicated in the disease; a difference which is easily explained by the greater length of the spinous pro- cess of the latter, as compared with that of the spinous processes of the ver- tebrae above. Abscess connected with diseased cervical vertebrae usually presents itself among the muscles on the side of the neck. Occasionally it makes its Avay forward, forming a tumor, and aftenvards breaking, in the pharnyx. I have seen one case in which the abscess penetrated into the theca vertebralis, and the whole of the spinal chord, from its origin to its termination, Avas bathed in pus. At an early period of the disease, the patient frequently complains of pains in the arms and shoulders. After some time these pains subside, but they are folloAved by complete paralysis of the upper extremities ; while the muscles Avhich derive their nervous influence from the spinal chord below the neck remain subject to the Avill. In a still more advanced stage of the disease, the paralysis extends to the muscles of the trunk and of the loAver extremities. Then there are pains in the abdomen, Avhich becomes distended and tympanitic j the bowels being at the same time obstinately costive. In all cases, there is pain in the occiput and temples ; which is, noAvever, most severe when the disease is situated in the two or three superior vertebrae. Not unfrequently the transverse ligament of the second vertebra is destroy- ed, and the consequence is, a dislocation of the odontoid process. Sometimes the dislocation is complete, and the patient, from the pressure made on the spinal chord, expires as suddenly as if the latter had been divided trans- versely. More frequently it happens that the displacement of the odontoid process is someAvhat restrained by the pressure of the dura mater Avhich lies over it. There is then some degree of pressure on the spinal chord, suffi- cient to excite irritation, but not sufficient to destroy its functions. Under these circumstances, the patient complains of increased pain in the head, fol- lowed by convulsions, stupor, dilated pupils, and other symptoms of effusion of fluid on the brain j and on examining the body, after death, we find that such effusion has actually taken place, there being a collection of fluid in the ventricles, or in the base of the cranium, or in both of these situations. In cases of caries of the superior dorsal vertebrae, independently of the usual pain and tenderness of the affected parts, the patient complains of pain and a sense of constriction of the chest; and \vhen the disease is in the infe- rior dorsal vertebras there is a similar sensation in the epigastrium, pain in DISEASES OF THE JOINTS. 97 the abdomen generally, and a disturbed state of the functions of the alimen- tary canal. Occasionally the urine is alkaline, or it contains albumen, being voided without its natural transparency, and becoming completely opaque on exposure to heat, or on the addition of nitric acid. From this last circum- stance, and from their being at the same time pain either in or near the region of the kidney, it is sometimes difficult, in the first instance, to de- termine whether the patient labors under caries of the spine or disease of the kidney. When the spine is incurvated forward, in consequence of the destruction of the bodies of the dorsal vertebras, the angular projection behind is more distinct than it ever is where the disease has attacked the vertebras of the neck or loins. This is to be attributed to the greater length of the spinous processes in this part of the spine, and to the circumstance of their being, in the ordinary position of the parts, inclined more or less downward. When the curvature is considerable the thorax becomes at the same time altered in figure. The diameter of the thorax, from above downwards, is rendered shorter, while the other diameters are increased ; so that, while the figure of the chest is altered, there is but little difference in its actual capacity. If, under these circumstances, an opportunity should occur of examining the appearances after death, we find a change in the position of the viscera cor- responding to the altered form of the cavity in Avhich they are contained. This is most apparent in the descending aorta, which is seen taking a spiral, instead of its usual straight course on the fore part of the spine. When the superior dorsal and inferior cervical vertebrae are both implicated in the dis- ease, a large protuberance presents itself between the superior angles of the scapulas, and the neck appears shortened, as if it had descended or sunk be- tAveen the shoulders. As the disease advances, the patient, in some instances, complains of pains, Avhich are referred to one groin and hip, such as may lead to the sus- picion that there is disease in the hip-joint; and, in fact, a very common error (and one into which even surgeons of great experience are liable to fall), to regard the symptoms of caries of the middle and inferior dorsal ver- tebras as indicating incipient caries of the hip. Afterwards pains, and a sense of constriction, are felt in the legs and thighs. Then the muscles are found to be not properly under the dominion of the will, so that the patient occasionally loses a step, or trips in Avalking. This is probably followed by a complete loss of voluntary power. In some cases there is an entire para- lysis ; the muscles of the lower extremities never acting under any circum- stances : while in other cases, although they do not act under the influence of volition, they are subject to involuntary contractions or spasms. Occasionally the loss of voluntary power over the muscles is attended with a total- loss of sensibility ; but more frequently while the former func* tion of the nerves is destroyed, the latter remains either little or not at all impaired. Paralysis of the bladder, and incontinence of the urine and fasces, some-i times occur in combination with paralysis of the loAver limbs, forming a most distressing addition to the patient's other calamities. A considerable time generally elapses before abscess connected Avith caries of the dorsal vertebrae presents itself externally. Sometimes it sIioavs itself on the posterior or lateral, or even on the anterior part of the chest, having penetrated through one of the intervertebral spaces. More commonly it makes its Avay dowiiAvards through the posterior mediastinum, and behind the email muscle of the diaphragm; and then, taking the course of the psoas 98 OBSERVATIONS ON THE muscle, passes behind the crural arch, and sIioavs itself in the anterior and upper part of the thigh. It is not uncommon for the abscess to form a large tumor on one side of the abdomen, occupying the Avhole, or a great part, of the space between the false ribs and the groin, pushing the viscera to the opposite side, and, at last, making its AAray to the surface through the abdomi- nal muscles. But a great length of time may elapse before it reaches this termination. I have known such an abscess to remain, neither increasing nor diminishing in size, nor being materially changed in its situation, for several successive years: in some instances being a soft and compressible tumor, in Avhich the fluctuation of matter was distinctly perceptible ; in others, appearing like an irregular mass of solid substance, closely attached to the posterior and lateral parts of the spine. When the lumbar vertebras are affected with caries, the patient usually complains of pain in the region of the loins ; Avhich is aggravated by stoop- ing, turning the body suddenly round, or by percussion. Sometimes the pain is confined to the vertebrae themselves ; while at other times it extends fonvards, in the direction of the lumbar nerves, to the sides of the abdomen and the crista of the ilium. When abscess is formed, it usually either descends in the direction of the psoas muscle, and presents itself behind the crural arch in the upper and anterior part of the thigh, or otherwise makes its Avay backAvards on the outer edge of the quadratus lumborum and sacro lumbalis muscles, showing itself on one side of the loins. In some rare cases, it takes the course of the spermatic chord, and forms a tumor projecting through the abdominal ring, such as a superficial observer might easily mistake tor a hernia ; or, it de- scends into the pelvis, and afterwards into the posterior part of the thigh, following the direction of the sciatic nerve, through the sacro-sciatic notch of the pelvis. Occasionally it reaches this last mentioned situation in ano- ther Avay. I have knoAvn an abscess to have descended from the loins, and presented itself as a tumor in the groin. Suddenly the tumor has disap- peared, and the patient has been led to entertain hopes of a speedy recovery. But these have been soon disappointed, in consequence of the discovery of a large collection of matter in the posterior part ot the limb, behind the little trochanter of the thigh. In a case of this kind, in which I had the opportu- nity of examining the morbid appearances after death, I found that the ab- scess had taken the course of the common tendon of the psoas magnus and iliacus interims muscles, to their insertion into the little trochanter, afterwards extending further backward, over the inferior edge of the quadratus J'emoris. I may take this opportunity of observing, that it is by no means uncommon, Avhatever part of the spine may be the seat of caries, to find an abscess thus altering its course, disappearing in one place, and sometimes afterwards showing itself in another; and this seems to afford a reasonable explanation of some of those cases, in which it has been supposed that an abscess has been suddenly removed by absorption. It very rarely happens that this disease, when confined to the loins, proceeds so far as to occasion any perceptible alteration in the figure of the spine; and this peculiarity is easily explained, by the greater magnitude of the bodies of the lumbar, as compared with those of the cervical or dorsal vertebrae, in consequence of which, the former are not destroyed by the same degree of caries which Avould be sufficient for the destructio'n of the latter. The same circumstance will also, in great measure, account for another peculiarity of this disease, when it affects the lower portion of the spine • namely, the absence, in the majority of cases, of pains, muscular spasms, pa- DISEASES OF THE JOINTS. 99 ralysis, and loss of sensibility in the lower limbs. In fact, in these cases it seldom happens that the caries extends so far as to reach the theca vertebra- lis. In one case, in Avhich the patient had complained of numbness of the legs and thighs, I found, on dissection, that the theca vertebralis was in no part exposed; but that there was a large abscess on each side surrounding the origin of the anterior crural and obturator nerves, and thus explaining the diminished sensibility of the parts to Avhich they Avere distributed. In systematic works on surgery, the lumbar or psoas abscess is usually described as if it were (in some instances at least) a specific or primary dis- ease, having its origin in the psoas muscle. But, according to all the experi- ence which I have had in these cases, this is altogether a mistaken view of the subject. I cannot say that such an abscess never takes place in the loins; but I certainly believe that it is of very rare occurrence. In examining cases of lumbar abscess after death, I have ahvays found caries of the vertebrae, in which the abscess has manifestly originated. In general the disease of the vertebrae has been so obvious, that it could not have been overlooked by the most superficial observer; but, in some instances, the real nature of the dis- ease has not been detected until after a careful dissection. In one instance, on examining the body of a patient who died in St. George's Hospital with an extensive suppuration in the loins, the soft parts having been entirely re- moved, not the smallest appearance of disease presented itself in the lumbar vertebrae, and I conceived that I had at last met with a case of genuine psoas abscess ; Avhen, almost accidentally, a small opening Avas discovered on one side of the spine, in a part Avhich had been covered by one of the attachments of the psoas muscle, just large enough to admit a common probe, and forming a communication between the cavity of the abscess, and one of the interver- tebral spaces. On a further dissection, it Avas ascertained that the interver- tebral cartilage had been completely destroyed by ulceration, except at its circumference, and that the opposite surfaces of the bodies of the tAvo conti- guous vertebrae were extensively carious. SECTION III. On the Treatment of Caries of the Spine. There are few case3 of caries of the spine in which it is not advisable to have recourse to some kind of medical treatment, for the purpose either of correct- ing that state of the system on Avhich the local disease depends, or of coun- teracting the ill effects which the latter has produced on the patient's general health. On this subject, however, it will be sufficient for me to refer to the observations Avhich I have already offered in speaking of the treatment of the diseases of the other articulations, in the concluding part of each of the two preceding chapters. Of those remedies Avhich may be supposed to exercise a more direct influ- ence over the disease, the two which have been principally recommended are ; first, a state of absolute rest in the horizontal position, continued during a considerable period of time ; and secondly, the establishment of issues made with caustic, or the actual cautery, in the neighborhood of the affected ver- I suppose that no one will be bold enough to deny the prudence, and that few will deny the absolute necessity, of the first of these remedies. While 100 OBSERA'ATIONS ON THE the patient is in the erect posture, and the Aveight of the head and other superincumbent parts are pressing on the ulcerated surfaces, and while these are liable, in the various motions of the body, to a constant (however trifling) friction, it is not probable that the progress of ulceration can be checked, or that suppuration can be prevented. From the first moment in which the nature of the case is clearly indicated, the patient should abandon his usual habits, and be confined altogether to his bed or couch. In some instances, in Avhich severe pain in the vertebrae is among the early symptoms of the disease, the patient will submit to the privations which are thus imposed upon him Avith sufficient Avillingness ; while in others, nothing but a candid exposition of the ill consequences which may othenvise arise, Avill overcome his reluc- tance to do so. The invalid bedstead, contrived by Mr. Earle, and which I have formerly mentioned, Avill, in ordinary cases, afford the most convenient means of conducting this part of the treatment The use of it is attended Avith this great advantage, that the patient may be laid on his back, and the trunk and thighs may be, from time to time, and within moderate limits, ele- vated or depressed, so that their relative position may be varied Avithout the smallest movement being communicated to the carious vertebrae. Where, hoAvever, the disease has been going on for a long time, and there exists already a considerable angular curvature of the spine, it is desirable that the patient should recline on his side rather than on his back ; or if he finds this in any Avay inconvenient or disagreeable, he should lie, not on an absolutely flat surface, but supported by cushions and pillows, so that the position, in which he is placed, may have no tendency to restore the spine to its original figure. In the management of these cases, it is important that Ave should ahvays bear in mind, that, without undue interference on the part of the sur- geon, the carious or ulcerated surface of the vertebra above will come in contact Avith that of the vertebra beloAv; and that it is to the union which takes place between them under these circumstances, at first by soft sub- stance, and afterwards by bony anchylosis, that we are to look for the pa- tient's recovery. In artificially straightening or elongating the incurvated spine, Ave necessarily disturb this curative process, and therefore all attempts to do so, whether by means of machinery, or by laying the patient in the supine posture on a horizontal board, are to be scrupulously avoided. The recumbent position does not constitute the only means Avhich Ave have it in our power to employ for the purpose of maintaining the diseased spine in a state of perfect repose. When the disease is situated in the dorsal or lumbar vertebras, the patient may be provided with a bandage, including some strips of whalebone, and somewhat resembling the stays Avorn by females, but extending as Ioav as the symphysis of the pubes, the os sacrum, and the great trochanter, and as high as the neck. This will operate like splints, fixing the pelvis and thorax in the same relative position. A less efficient eupport may be given to the cervical vertebrae, by means of a cushion adapted to the shade of the lateral and posterior parts of the neck, and extending from the upper part of the back to the occiput. Concerning the advantage to be derived from the establishment of issues there may probably be a greater diversity of opinion than concerning that which is to be obtained from rest and the recumbent posture 5 and I am Avell aAvare that some experienced practitioners of the present day estimate their value at a low rate. It is not, however, easy to suppose that Mr. Pott and others, whose opinion carries with it much authority, should have been mis- taken so far as to persevere, during a series of years, in the employment of a remedy which was actually inefficacious. If issues are of service where the DISEASES OF THE JOINTS. 101 cartilages of the hip or knee are ulcerated, analogy would lead us to expect, that they may be useful also, where a corresponding disease has taken place in the joints of the vertebrae; and my OAvn experience has certainly tended to confirm this expectation. I have known instances of patients, who have been under precisely the same circumstances with respect to rest, and Avhose symptoms have been manifestly and considerably relieved, either immediately or in a short time, after the issues had been made; and, where the caustic has been occasionally applied to the surface of the issue for the purpose of keeping it open, other patients have informed me, that " they have uniformly found themselves better in a few hours after each application." At the same time, it must be acknoAvledged, that some cases occur, in Avhich the caustic issues seem to be productive of little or no benefit. Probably it is with dis- eases of the vertebral as it is with those of the other joints, and issues may be of little or no efficacy where the ulceration of the cartilages is preceded by a scrofulous disease of the cancellous structure of the bones; and they may be productive of great benefit where it takes place under other circum- stances. Nor, if my observations on the subject be Avell founded, is this to be regarded as a merely theoretical opinion. 1 have repeatedly known the greatest relief to follow the establishment of issues, where the patient has suffered severe pain in the situation of the carious vertebrae, presenting at the same time no distinct indications of a scrofulous diathesis ; Avhile, in young persons, Avith fair complexions, and dilated pupils, in whom the disease has proceeded with little or no pain, they have appeared to be either inefficacious, or actually injurious. It appears to me also, that in caries of the spine, as well as in that of other joints, issues are to be employed only in the early stage of the disease, with a view to prevent suppuration, and that they are of no service after abscess has actually formed. An important question remains : how long is the use of these remedies to be continued ? It is often difficult to ansAver such an inquiry even in an individual case; and it is much more so to lay down a general rule on the subject. The issues may be healed on the first clear evidence of the forma- tion of abscess; otherwise, if they occasion little or no inconvenience, they may be kept open for one or two years. With respect to the recumbent position, if there be a reason for having recourse to it, there is also a suffi- cient reason for it not being abandoned, in less than six or seven months, even Avhen the disease is in its earliest stage; and, in the great majority of cases, the period should be extended to a year, and sometimes to a year and a half. In the first instance, the surgeon usually finds it difficult to persuade the patient to continue this part of the treatment for a sufficient length of time after the removal of the more urgent symptoms. Aftenvards, however, he has to encounter a difficulty of an opposite kind. This happens especially amon°- young females ; who often become at last so habituated to then- ecu^ and the peculiar mode of life connected Avith it, that they can scarcely be persuaded to make the necessary effort to sit up and move about, even after every reason for not doing so has vanished. I knoAv an instance of a lady, Avho, under these circumstances, has preserved the horizontal position for twelve' years; and in whom nearly all the joints of the loAver extremi- ties, in which no actual disease ever existed, have, from mere Avant of exer- cise', become firmly anchylosed ; so that it seems more than probable that nothino- which can noAV be done will enable her to regain the use of the limbs, or even to sit up. . With respect to the treatment of abscesses connected with caries ot the spine, I am not aware of any circumstances in Avhich it should differ from 102 OBSERVATIONS ON THE that of abscesses connected with other joints affected by the same disease. The patient should not venture to take exercise, nor even to quit the recum- bent posture until the abscesses are healed. This is to be regarded as the general rule ; from Avhich, hoAvever, on a very few occasions, it may be right to deviate. I Avas consulted by a gentleman avIio Avas at that time thirty-five years of age, and who had labored under Avell-marked symptoms of caries of the spine, since he was three years old. There was considerable curvature in the direction forward, with an angular projection of the spinous processes of the middle dorsal vertebrae posteriorly ; and there Avere two sinuses discharg- ing pus communicating Avith the carious vertebrae Avhich had existed for nearly thirty years. Nevertheless, the patient had been able to take violent exer- cise in hunting, and shooting, and other Avays, and his general health had been excellent In fact, he had suffered no material inconvenience from his complaint, except that he once lost the use of his loAver limbs ; recovering it, however, completely at the expiration of three months, and after the applica- tion of blisters to the back. DISEASES OF THE JOINTS. 103 CHAPTER VII. ON TUMORS AND LOOSE CARTILAGES IN THE CAVITIES 07 JOINTS. The loose cartilaginous substances, which are sometimes found in the joints have been so frequently described by writers, that I can have but few ob- servations to offer respecting them. I believe it is generally supposed that these loose bodies have their origin in coagulated lymph, Avhich has been effused from inflammation of the inner surface of the synoArial membrane, and which has aftenvards become vascular. In the majority of cases, however, Avhich I have met Avith, no symptoms of inflammation preceded their forma- tion ; and hence it is probable that, in some instances, they are generated, like other tumors, in consequence of some morbid action of a different nature. They appear to be situated originally, either on the external surface, or in the substance of the synovial membrane; since, before they have become detached, a thin layer of the latter may be traced to be reflected over them. My own experience is much in favor of the removal of these loose carti- lages by an incision of the joint, provided that this be done in a cautious and prudent manner. The patient should be kept in a state of the most perfect quietude for two or three days preceding, and for several days after the operation. The cartilage having been well fixed, the different parts over it should be slowly and separately divided until it is exposed. The Avound of the synovial membrane may be dilated by means of a probe-pointed bis - toury, until it is of sufficient size to allow of the cartilage being extracted with a tenaculum; and the cut edges of the skin should be instantly re- placed in contact with each other, and secured by means of adhesive plaster. I attended a gentleman avIio labored under this troublesome disease, and in Avhom the loose bodies not unfrequently slipped between the articulating surfaces of the knee, occasioning an almost immediate swelling of the joint, Avith the most excruciating pain and tenderness, and much symptomatic fever. In one instance more than a month elapsed before these symptoms had subsided. These circumstances are noticed, because they prove that, in this patient, there Avas a considerable disposition to inflammation, yet by attending to the precautions above mentioned, as many as five loose carti- lages Avere extracted by three different operations, without the slightest in- convenience from any one of them. I have seen two cases, in which the loose bodies Avere of a different na- ture, and had a different origin from those which are commonly met Avith. It occasionally happens, that a bony ridge is formed, like small exostosis, round the margin of the cartilages of the joint. In the Iavo cases to which I allude, this preternatural growth of bone had taken place, and in conse- quence of the motion of the parts on each other, portions of it had been broken off, and lay loose in the cavity of the joint. In the museum of St. George's hospital there is a specimen of a knee-joint, the inner surface of which is lined by a great number of small pendulous 104 OBSERVATIONS ON THE excrescences, connected with the synovial membrane ; having a smooth ex- ternal surface, and bearing an apparent resemblance to the appendices epiploi- ca of the great intestine, though not like them containing adipose substance. The preparation was purchased at the sale of the late Mr. Heaviside's anato- mical collection; and nothing is known of the history of the patient from whom it was taken. We have another somewhat similar specimen ; and, in the last case, there is reason to believe that the excrescences were the result of long-continued inflammation of the synovial membrane. A third example of the same disease is in Sir Charles Bell's museum, which was formerly in Great Windmill Street. The late Mr. Shaw informed me that, in this case, the joint contained a considerable quantity of whey-like fluid ; but he was not able to give me any further information respecting it. Occasionally, tumors of a different kind are formed on the inner surface of the synovial membrane, and attain a considerable magnitude. Case LXVIIL—Morris Sudbury, twenty-one years of age, was admitted into St. George's Hospital, on the 4th of October, 1820. He had swelling, and complained of pain and tenderness, in one knee. He was kept in bed : the joint was bathed Avith a cold lotion. Afterwards blis- ters Avere applied. The SAvelling subsided, but the joint continued weak and painful. On the 11th of December, for the first time, a tumor was discovered evi- dently Avithin the cavity of the knee-joint, situated on the edge of the patella, over the external condyle of the femur. The tumor appeared like a loose car- tilage, of about the size and form of an almond. When the man attempted to Avalk, in certain motions of the limb, it slipt into the cavity of the joint, pro- ducing considerable distress, and making him lame. An attempt Avas made to confine it by means of bandages, but Avithout success. On the 5th of January, 1821, Mr. Ewbank made an incision through the. skin, fascia, and synovial membrane, so as to expose the tumor. It was found to be not cartilaginous, but of a gristly structure, It Avas of about the length of an almond, but rather broader; and it Avas attached by one extre- mity to the .synovial membrane, near the edge of the patella. This attach- ment Avas cut through, and the tumor Avas removed. The edges of the wound were brought into contact, and united by the first intention. Some inflammation of the joint followed, but Avas subdued Avithout much difficulty. When the patient began to Avalk, he found himself to have been much re- lieved by the operation. Six Aveeks afteiAvards, however, a tumor Avas discovered in the knee of a smaller size than that Avhich had been removed, but occupying precisely the same situation; so that there Avas sufficient reason to believe that it had groAvn from the same basis. This tumor could be pressed into the joint by the fingers, but did not slip into it spontaneously in Avalking ; and there- fore at the time the man left the hospital, he did not suffer any inconve- nience from it. Case LXIX.—Mr. H., a young man, consulted me on the 25th of April, 1822, laboring under the following symptoms:—In certain motions of the right knee a tumor presented itself on the inside of the patella, which had been supposed to be, and had the appearance of being, a loose cartilage of a large size. He said that, occasionally, in walking, this substance slipped between the articulating surfaces. The accident ahvays produced conside- rable pain at the time, and an inflammation of the synovial membrane after- wards, which in one instance confined him to his bed for several weeks. He DISEASES OF THE JOINTS. 105 said, further, that these symptoms had been gradually coming on for two or three years ; that he had Avorn bandages, without experiencing any good ef- fect ; and that, as the disease interfered very much Avith his comfort and occupations, he Avas desirous of submitting to any operation which afforded him a prospect of relief. On the 28th of April, after he had remained for one or two days in a state of perfect quietude, I carefully made an incision on the tumor, which had been previously fixed by the finger of an assistant over the inner condyle of the femur. When it Avas thus exposed, I found the tumor to be, not a loose cartilage, but of a fleshy structure ; and that it was connected to the synovial membrane, beloAV the patella, by a broad adhesion. Having divided this adhesion, I removed the tumor. The edges of the wound were brought together by means of a suture, Avhich A\as passed through the integuments, and strips of adhesive plaster. The patient was kept in bed, and the limb was supported by a splint, to which it Avas secured by bandages in such u way as to render the joint quite incapable of motion. About twenty -two hours after the operation, symptoms of a violent inflam- mation began to show themselves. There Avas almost insupportable pain ; the joint' became rapidly swollen ; the pulse rose to 90 in a minute, and was hard and strong. By means of very active antiphlogistic treatment, how- ever, the inflammation subsided, without producing any bad consequences, On the 27th of June he Avas able to undertake a journey to a considerable distance from London ; at which time the knee was neither swollen nor pain- ful, but it Avas still incapable of perfect flexion and extension. On examining more accurately the tumor Avhich had been removed in this case, it was found to be about two inches and a half in length, and one inch and a half in breadth, and someAvhat less than half an inch in thickness in the thickest part; convex on one surface, and somewhat flattened on the other. It Avas of a firm., fleshy structure. The general appearance of it a good deal resembled that of the coagulum which is found in the sac of aneurism; but it Avas not laminated: it had a smooth membranous surface; and it Avas mani- festly organised, as vessels might be distinctly traced ramifying through its substance.* In both of these cases the operation was resorted to under the impression that the substance contained in the cavity of the joint Avas one of the loose cartilages, of which I have spoken in the beginning of this chapter. If I had been acquainted Avith the real nature of the tumor in the last case, I should certainly have been less inclined to attempt its extirpation ; and the violence of the inflammation which ensued must form an additional reason for hesitation in any future case of the same kind. But the question will arise, how are such firm fleshy tumors, Avhich are capable of altering their position in the cavity of a joint, and which product symptoms similar to those Avhich are produced by loose cartilages, to be dis- tinguished from the latter? Perhaps, being aware of the possibility of_the existence of a tumor of this description, Ave may, by a very careful examina- tion, be enabled to ascertain, even through the superjacent soft parts, that it * A remarkable circumstance occurred in the progress of this case. The wound made in the operation united by the first intention ; but the joint being much distended with synovia, the adhesion gave way; so that the wound was reopened on the ninth or tenth day, and the synovia escaped in a small but constant stream. The discharge of synovia continued ; but the joint being carefully retained in a state of the most perfect quietude, supported on a splint. no additional inflammation of it was the consequence. At last the flow of synovia ceased ; the wound gradually closed; and in the course of three or four weeks it was firmly cicatrised. 14 106 OBSERVATIONS ON THE has not the same degree of hardness Avith cartilage itself. I am not at pre- sent acquainted Avith any other circumstances on wrhich our diagnosis can be founded. Fortunately, however, it happens, that, Avhile loose cartilages in joints are not uncommon, such fleshy tumors as I have just described are of very rare occurrence. DISEASES OF THE JOINTS. 107 CHAPTER VIII. ON MALIGNANT DISEASES OF THE JOINTS. It is well known to surgeons, that the bones are liable to those morbid growths and alterations of structure, which, from the peculiar circumstances Avhich mark their progress, are usually denominated malignant diseases. In the cases Avhich have fallen under my observation, carcinoma of the bones has never occurred as a primary disease, but has ahvays been pre- ceded by carcinoma of the breast or some other glandular organ. The exis- tence of the disease in the bones has been indicated by pains, sometimes slight, at other times most severe, resembling those of deep seated rheuma- tism, but not yielding to the use of the remedies by Avhich rheumatic pains are usually influenced. In these cases, the bones themselves become un- naturally brittle, and are so easily broken, that I have more than once known a fracture of the femur to be produced by the patient accidentally turning herself in bed ; and, in one instance, a fracture of the clavicle took place on the patient making some slight effort in raising her arm. Of the two following cases the first affords an example of carcinomatous disease affecting the head of the femur, and producing symptoms somewhat corresponding to those of disease in the hip-joint; while the second displays the symptoms which it produces Avhen it attacks the vertebrae, and which are such as might lead a superficial observer to mistake the case for one of caries of the spine. Case LXX.—A lady, between sixty and seventy years of age, in the year 1817, underwent the operation for the removal of a scirrhous breast. Some time afterwards a hard tumor showed itself in the cicatrix; and, about the same period, she began to complain of pain in the left hip and thigh. On the 7th of November, 1820, I saAV her in consultation Avith Mr. Smith, sur- geon, of Richmond, by Avhom she was attended. At this time a large scirr- hous tumor occupied the situation of the breast which had been amputated. She complained of pain in the hip, thigh, and knee, which was aggravated by pressure : the pain was very severe, keeping her awake at night, except Avhen she was under the influence of a very large dose of opium. There was a cluster of enlarged glands in the groin, making a hard, and somewhat movable tumor. On the 18th of December following, the patient died ; and the body was examined by Mr. Smith and myself on the folloAving day. We found that the thigh bone had been broken transversely about two inches below the neck; and it was evident, from the appearance of the frac- ture, that it had taken place immediately before or after death ; and, in either case, it must have been the result of some very trifling accident. The whole of the superior extremity of the thigh-bone Avas softer and more brit- tle than natural: but this morbid change Avas less distinct below than above the fracture, and it was most distinct in that part of the head of the bone which Avas contiguous to the cartilage. On making a section of the head and neck of the bone, the earthy matter Avas found to be very deficient, and ;t cartilaginous or gristly substance Ava» seen blended with the bony structure. 108 OBSERVATIONS ON THE In several places there Avere spots of increased vascularity with deposition of some cheesy matter in the centre. The cartilages were not ulcerated, and there was no effusion of pus, lymph, or serum into the cavity of the joint. The enlarged inguinal glands had the structure of scirrhus ; and there Avas a similar mass of scirrhous lymphatic glands in the pelvis, immedi- ately above the crural arch. Case LXXI.—A lady, about thirty-eight years of age, consulted me, in the spring of 1832, on account of a scirrhous disease of one breast. There Avas not a distinct scirrhous tumor imbedded in the substance of the breast, but a conversion of the gland itself into the scirrhous structure. The skin covering the breast was thickened, and manifestly contaminated by the disease. From this time I saAv her occasionally ; the disease in the breast making little or no apparent progress. During the night of the 10th of February 1833, she suddenly became para- lytic in the whole of the lower part of her person. She not only lost the power of using her loAver limbs, but that of voiding her urine also ; and it became necessary to empty the bladder by means of a catheter. The loss of muscular power was attended with a loss of sensibility as high as the navel and loAvest dorsal vertebrae. When the catheter was introduced into the bladder she Avas not sensible of its introduction. In the beginning of March the lower limbs became affected Avith invo- luntary convulsive movements, which Avere unattended by pain, but of Avhich the patient complained that it Avas disagreeable for her to see them. When the paralysis first took place the urine Avas clear, and otherwise in a natural state, afterwards it became ammoniacal, and offensive to the smell, depositing a thick mucus, with traces of phosphate of lime in it On the 9th of April, 1833, the patient died. The body was examined by Mr. Cutler, Avho found the Avhole of the gland of the breast to have assumed a scirrhous structure. Several of the dorsal vertebrae Avere converted into a substance possessing considerable vascularity, of a gristly consistence; some of them containing no earthy matter whatever, so that they could be cut with a knife. Altogether, the alteration in the condition of the vertebrae seemed to be very similar to that Avhich had taken place in the head of the femur, in the case Avhich Avas last described, except that, being more complete, it might be supposed to indi- cate a more advanced stage of the disease. The Avhole of the lower portion of the theca vertebralis Avas filled with a serous fluid. There Avas a deposit of earthy matter in the upper part of each lun°-; and about four ounces of serous fluid Avere contained in the cavity of the riffht pleura. The kidneys Avere of a dark color, and highly vascular. The mucous membrane of the bladder bore marks of considerable inflam- mation. The ureters pelves, and infundibula of the kidneys Avere also in- flamed, and in some parts lined Avith coagulated lymph. They were consi- derably dilated, and contained a putrid mixture of urine and mucus. The bones are much more liable to be affected by fungous haematodes than they are by carcinoma; and the former frequently occurs in them as a pri- mary disease, that is, not having previously shown"itself in any other part of the body. Several cases have fallen under my observation, in Avhich a tumor of this description has had its origin in one of the bones of a joint; and it is evident that such a tumor, in its progress affecting the contiguous parts, DISEASES OF THE JOINTS. 109 must, by degrees, render the joint useless, and terminate in its complete de- struction. In these cases the patient first complains of a slight degree of pain in the affected part, Avhich is somewhat aggravated by exercise. Some time after- wards the bone is observed to be slightly enlarged. As the tumor increases, it is found to be elastic in some parts, hard in others. For a considerable time it does not interfere with the functions of the joint; Avhich, however afterwards becomes limited in its motions, and, ultimately, completely fixed in one position. I have never knoAvn but one case in Avhich the patient did not submit to amputation before the disease had reached its most advanced stage; and here the skin became ulcerated, and a large ill-conditioned sore was the consequence. Amputation is, indeed, the only remedy which the surgeon has to offer; and it is unnecessary to say, that, in all cases of fungous haematodes, even this is of doubtful efficacy. In the first of the tAvo following cases I had, however, the satisfaction of learning that the patient continues well at the present time, and more than four years after the operation. Case LXXII.—Mr. O., twenty-five years of age, in January, 1828, first experienced a sensation of weakness in the right knee, with a slight pain, after walking even a short distance. These symptoms continued ; and, in the course of two or three months, he observed a small tumor over the external condyle. He remained in this state, the tumor not increasing in size, through the spring, and the greater part of the summer. In the middle of the folloAving August, he one day Avent through a great deal of fatigue in grouse shooting; after Avhich the tumor began to increase in size. On the 1st of September, in Avalking over a field, his foot slipped into a hollow in the ground. This caused great pain in the knee, and he Avas under the necessity of riding home. After this accident the tumor progressively increased in size. On the 25th January, 1829, he came to London, and pla- ced himself under the care of Mr. Griffiths, of Pimlico, and myself. At this time, there Avas a very considerable enlargement of the Avhole of the upper part of the knee-joint, so that it was four inches in circumference larger than the corresponding part of the opposite limb. The tumor Avas soft and elastic, occupying the situations of both condyles of the femur, but being more especially prominent in that of the outer condyle. The head of the tibia and the patella did not seem to be implicated in the disease, and the joint re- tained nearly its natural degree of mobility. For some time after I Avas consulted the tumor remained nearly station- ary : then it began to increase ; and, as no remedy seemed to have any do- minion over the disease, a consultation was held with Sir Astley Cooper, in Avhich it Avas determined that the limb should be removed by amputation. The operation was accordingly performed on the 6th of July, 1829. On examining the amputated limb, the femur Avas found to terminate abruptly about five inches above the knee-joint. In place of the condyles, and loAver part of the shaft of that bone, there Avas a large tumor, of an ir- regular form, of that structure to Avhich the name of fungous haematodes is commonly applied. The cartilage which had covered the surface of the con- dyles of the femur Avas seen expanded over the lower part of the tumor; being every Avhere thinner than natural, but no Avhere in a state of ulceration. In some parts it had contracted adhesions to the cartilage covering the head of the tibia. 110 OBSERVATIONS ON THE In other parts the tumor Avas covered by some thin remains of the peri- osteum, and a layer of thickened cellular membrane. Case LXXIIL—William Williamson, fourteen years of age, Avas admit- ted into St. George's Hospital on the 21st of September, 1831, on account of a tumor on the inside of the right knee, extending from about two inches below the tubercle of the tibia upward, over the inner condyle of the femur, as high as one fourth of that bone, and backAvard so as to occupy the ham. The boundaries of the tumor Avere distinctly defined. It seemed to have had its origin in the head of the tibia, and the tendons of the inner ham- string were seen stretched over its surface at the upper part, and apparently terminating in it beloAv. The circumference of the knee-joint, in the situa- tion of the tumor, Avas eighteen inches. The skin covering the tumor was tense and shining, with large tortuous veins ramifying in it. On examining it Avith the hand, some parts of the tumor were found to be hard, while other parts Avere soft and elastic. The joint admitted of some degree of motion, but Avas kept in the half- bent position. The tibia appeared to be the only bone implicated in the disease. The patient had, generally, had good health ; and seemed to be free from all other disease at the time of his being admitted into the hospital. He stated that, in April, 1831, he first experienced a slight degree of pain in the head of the tibia, especially in Avalking. About six weeks afterwards he observed a slight enlargement of the bone, Avhich from that time gradu- ally increased. September 29. The limb was amputated. On examining the knee-joint, the tumor Avas found to be Avholly formed by an expansion of the head of the tibia. The upper and inner part of the tumor was composed, partly of cysts containing a bloody fluid, and partly of organised medullary substance. In other parts there was a mass of bony and cartilaginous substance, disposed in fibres, which seemed to proceed from what had been the surface of trie original bone, and presented a someAvhat radiated appearance. The other bones, the cartilages, and the soft parts composing the joint, Avere in a natural state. DISEASES OF THE JOINTS. Ill CHAPTER IX. ON SOME OTHER DISEASES OF THE JOINTS. In the present chapter, it is proposed to notice some other diseases of the joints, which have not been described in the former pages. 1. In those numerous cases in which acute inflammation attacks the shaft of a cylindrical bone, and the periosteum covering it, the disease is usually limited by the epiphysis ; so that, notwithstanding the extensive abscesses and exfoliations Avhich frequently ensue, the neighboring joints are not affected by'xt A fevv instances, however, occur, in which acute inflammation attacks the epiphysis itself, terminating also in more or less extensive exfoliation.. Some- times we find nearly the whole of the epiphysis deprived of its vitality; at other times only one small portion of it, or several small portions in different places. In some of these cases, the exact nature of the disease is sufficiently ob- vious ; but in others, Avhere the exfoliations are of a very small size, it is difficult, or impossible, to form an exact diagnosis. This is, however, of the less importance, as, under all circumstances, such a disease must terminate in the complete destruction of the joint; so that there is no remedy but am- putation. 2. Chronic inflammation, producing a chronic enlargement of the epiphysis, is a not unfrequent occurrence, and is liable to be mistaken for disease in the joint itself; the more so, as inflammation of the synovial membrane some- rimes occurs as a secondary disease. The patient, under these circumstan- ces, may derive benefit from the use of sarsaparilla, mercury, the tincture of iodine, mezereon, or from the application of blisters; in short, from any of those remedies which are found to be useful Avhere nodes are formed in other parts of the bones. Occasionally chronic inflammation of an epiphysis terminates in the for- mation of an abscess in the centre of the bone, but contiguous to the joint. An abscess of this kind is attended Avith an extraordinary degree of suffering, such as not only justifies amputation, but induces the patient cheerfully to submit to the operation. Under certain circumstances, however, he may obtain the desired relief Avithout the loss of the limb. The folloAving cases will serve, to illustrate both the history and treatment of these cases, and will be found interesting to the practical surgeon. * Case LXXIV.—Mr. P., about twenty-four years of age, consulted me in October, 1824, under the following circumstances :— There Avas a considerable enlargement of the lower extremity of the right tibia, extending to the distance of two or three inches from the ankle-joint. The integuments at this part Avere tense, and they adhered closely to the surface ot the bone. The patient complained of a constant pain, referred to the enlarged bone * These cases formed the subject of a paper which I formerly communicated to the Medico- Chirurgical Society, and which has been published in the 17th volume of their Transactions. H.2 OBSERVATIONS ON THE ar.d neighboring parts. The pain Avas ahvays sufficiently distressing; but he Avas also liable to more severe paroxysms, in Avhich his sufferings were des- cribed as most excruciating. These paroxysms recurred at irregular inter- vals, confining him to his room for many successive days, and being attended Avith a considerable degree of constitutional disturbance. Mr. P. described the disease as having existed more than tAvelve years, and as having ren- dered his life miserable during the Avhole of that period. In the course of this time he had been under the care of various surgeons, and various modes of treatment had been resorted to Avithout any permanent adArantage. The re- medies Avhich I prescribed for him Avere equally inefficacious. Finding him- self without any prospect of being relieved by other means, he made up his mind to lose the limb by amputation; and Mr. Travis having seen him with me in consultation, and having concurred in the opinion that this Avas the best course Avhich could be pursued, the operation was performed accordingly.* On examining the amputated limb, it Avas found that a quantity of new bone had been deposited on the surface of the lower extremity of the tibia. This deposition of' new bone was manifestly the result of inflammation of the peri- osteum at some former period. It was not less than one third of an inch in thickness ; and, Avhen the tibia was divided longitudinally Avith a saw, the line at Avhich the new and old bone Avere united Avith each other Avas distinctly to be seen. The Avhole of the loAver extremity of the tibia Avas harder and more com- pact than under ordinary circumstances, in consequence, as it appeared, of s:>ine deposit of bone in the cancellous structure; and in its centre, about one third of an inch above the ankle, there was a cavity of the size of an or- dinary Avalnut, filled Avith a dark-colored pus. The bone immediately sur- rounding this cavity Avas distinguished from that in the neighborhood by its being of a Avhiter color, and of a still harder texture, and the inner surface of the cavity presented an appearance of high vascularity. The ankle-joint Avas free from disease. It seems highly probable that, if the exact nature of the disease had been understood, and the bone had been perforated Avith a trephine, so as to allow the pus collected in its interior to escape, a cure Avould have been effected, Avithout the loss of the limb, and with little or no danger to the patient's life. Such, at least, was the opinion Avhich the circumstances of the case led me to form at the time; and I bore them in my mind, in the expectation that, at some future period, I might have the opportunity of acting on the knoAvled"-e Avhich they afforded me for the benefit of another patient. Case LXXV.—Mr. B., at that time twenty-three years of age, consulted * It is right that I should state briefly the termination of the case ; especially as the circum- stances attending it were probably connected with a peculiar condition of the nervous system, occasioned by the long continuance of the local disease. Unfortunately I preserved no notes of this part of the case at the time; but I have no doubt that my recollection is accurate as to the following particulars. The patient bore the operation with the utmost fortitude, but imme- diately afterwards he was observed to become exceedingly irritable, restless, and too much disposed to talk. Unfortunately, in the evening there Was haemorrhage from the stump ; which ceased, however, on removal of the dressings and coagulum. Durin°- the ni°-ht he had no sleep ; and on the following day he was restless and incessantly talking, with a rapid pulse These symptoms became aggravated. There was no disposition to sleep, and the pulse became so rapid that it could be scarcely counted. Until the third or fourth day the tongue remained clean and moist. After this period it became dry, and somewhat brown, and there was constant delirium. The pupils were widely dilated, and the sensibility of the retina Avas totally des- troyed ; the glare of a candle not being perceptible even when held close to the eye. Death took place on the fifth day after the operation. No morbid appearances were observed in the post mortem examination. DISEASES OF THE JOINTS. 113 me in the beginning of February, 1826. There Avas considerable enlarge- ment of the right tibia, beginning immediately beloAv the knee, and extending downwards, so as to occupy about one third of the length of the bone. Mr. B. complained of excessive pain, Avhich disturbed his rest at night, and some parts of the swelling Avere tender to the touch. The knee itself was not SAVollen, and its motions Avere perfect. He said that the disease had begun more than ten years ago, with a slight enlargement and pain in the upper extremity of the tibia; and that these symptoms had gradually increased up to the time of my being consulted. Various remedies had been employed, from Avhich, however, he had derived little or no advantage. Having inquired into the circumstances of the case, I Avas led to regard it as one of chronic periostitis ; and I adopted the following method of treat- ment :—An incision Avas made longitudinally on the anterior and inner part of the tibia, extending from the knee four inches doAvnwards, and penetrating through the periosteum into the substance of the bone. The periosteum Avas found considerably thickened, and the neAv bone, which had been deposited beneath, Avas soft and vascular. The immediate effect of the operation Avas to relieve the pain which the patient suffered, so that he slept Avell on the next and every succeeding night. After this I prescribed for him a strong decoc- tion of sarsaparilla. The wound gradually healed ; and it was for some time supposed that a perfect cure had been accomplished. The enlargement of the upper extremity of the tibia, however, never entirely subsided ; and in August, 1827, pain was once more experienced in it. At first the pain was trifling, but it gradually increased; and Avhen I was again consulted, in January, 1828, Mr. B. Avas unable to walk about, and quite unfit for his usual occupations. At this period the pain Avas constant, but more severe at one time than at another, often preventing sleep during several successive nights. The enlargement of the tibia was as great as Avhen I Avas first con- sulted ; and the skin covering it Avas tense, and adhering more closely than is natural to the surface of the bone. Some remedies Avhich I prescribed were productive of no benefit. The patient's sufferings Avere excruciating, and it was necessary that he should, if possible, obtain immediate relief. The re- semblances between the symptoms of this case and those of the case already described, Avere too obvious to be overlooked. It appeared highly probable that they depended on the same cause ; and I therefore proposed that the bone should be perforated Avith a trephine, in the expectation that an abscess Avould be discovered in its interior. To this the patient readily assented; and, accordingly, the operation Avas performed in the beginning of March, 1828. My attention was directed to a spot about two inches below the knee, to which the pain Avas especially referred. This part of the tibia Avas exposed by a crucial incision of the integuments. The periosteum noAV Avas not in the same state as at the time of the former operation: it Avas scarcely thicker than natural, and the bone beneath Avas hard and compact. A trephine of a middle size Avas applied, and a circle of bone Avas removed, extending into the cancellous' structure, but no abscess Avas discovered. I then by means of a chisel, re- moved several other small portions of bone at the bottom of the cavity made by the trephine. As I Avas proceeding in this part of the operation, the pa- tient suddenly experienced a sensation, Avhich he aftenvards described as beino- similar to that Avhich is produced by touching the cavity of a carious tooth, but much more severe, and immediately some dark-colored pus Avas seen to issue sloAvly from the part to Avhich the chisel had been last applied. This Avas absorbed by a sponge, so that the quantity of pus Avhich escaped 15 114 OBSERVATIONS ON THE was not accurately measured ; but it appeared to amount in all to about two drams. From this instant the peculiar pain belonging to the disease entirely ceased, and it has never returned. The patient experienced a good deal of pain—the consequence of the operation—for the first twenty-four hours; after Avhich there Avas little or no suffering. The wound was dressed lightly to the bottom with lint: nearly six months elapsed before it Avas completely cicatrized; but, in about three months from the day of the operation, Mr. B. was enabled to walk about and attend to his usual occupations. He conti- nued Avell when I last saAv him, on the 7th of January, 1832; and the tibia was then reduced in size, so as to be scarcely larger than that of the other leg. No exfoliation of bone had ever taken place. Case LXXVI.—In the beginning of January, 1830, Mr. S., thirty-four years of age, consulted me on account of the folloAving symptoms :— The lower extremity of the left tibia Avas considerably enlarged ; the skin covering it was tense, and adhered closely to the parts below. The patient complained of a constant aching pain, Avhich he referred to the enlarged bone. Once in tAvo or three weeks there Avas an attack of pain more severe than usual, during which his sufferings were excruciating, lasting several hours, and sometimes one or tAvo days, and rendering him altogether incapable of following his usual occupations. The pain was described as shooting and throbbing, Avorse during the night, and attended with such exquisite tender- ness of the parts in the neighborhood of the ankle, that the slightest touch Avas intolerable. Mr. S. said, that to the best of his recollection, the disease had begun eighteen years ago, in the following manner :—On going to bed one evening, he suddenly experienced a most acute pain in the inner ankle. On the fol- lowing morning he Avas unable to put his foot to the ground, on account of the agony Avhich every attempt to do so occasioned. Leeches Avere applied se- veral times, and afterwards blisters ; but the pain increased notwithstanding:. After some Aveeks an abscess presented itself, and broke. This Avas followed by some mitigation of the symptoms. Soon aftenvards another abscess formed, and broke in the neighborhood of the first. The tAvo abscesses re- mained open for a considerable time, and then healed rapidly. Mr. S. hoav began to regain the use of his limb, and, by degrees, Avas able to Avalk as usual. During the following summer he had a recurrence of pain in the inner ankle, Avithout any further formation of abscess. For eight or ten years after- Avards there were occasional attacks of pain, lasting one or tAvo davs at a time; the intervals betAveen them being of various duration, and, in one instance, not less than nine months. After this the attacks recurred more frequently; and, during the whole of the last two years, the symptoms Avere nearly as severe as at the time of my being consulted. On examining the limb, I Avas struck Avith the resemblance Avhich it bore to that of the limb in each of the two preceding cases. There was also a re- markable resemblance in the symptoms as described by the patient, and I could not but suspect that they depended on a similar cause. I requested that Mr. Travers, who had attended one of the former cases Avith me, should be con- sulted ; and he agreed with me in the opinion, that probably an abscess exis- ted in the centre of the tibia, and that it would be advisable to perforate the bone Avith a trephine, with the view of enabling the contents of the abscess to escape. Accordingly, I performed the operation, Avith the assistance of Mr. Travers, on the 31st of January. A crucial incision Avas made through the skin, the angles of which were raised, so as to expose a part of the bone above the in- DISEASES of the joints. 115 ner ankle, to which the pain was especially referred. A small trephine was then applied, and a circular portion of bone was removed, extending into the cancellous structure. Other portions of bone were removed with a narrow chisel. At last, about a dram of pus suddenly escaped, and rose into the opening made by the trephine and chisel. On further examination, a cavity Avas discovered, from Avhich pus had floAved, capable of admitting the extremity of the finger. The inner surface of this cavity was exquisitely tender, the patient experiencing the most excruciating pain on the gentlest introduc- tion of the probe into it. He passed a tolerable night, and suffered but little on the folloAving day. He continued to go on favorably until the 5th of February ; Avhen a violent inflammation attacked the limb immediately above the inner ankle. In spite of the application of leeches, an abscess formed, Avhich, in the course of six or seven days, presented itself immediately below the part at which the tre- phine had been applied. An opening was made Avith a lancet, and a consi- derable quantity of pus escaped, which had apparently formed betAveen the periosteum and bone ; the latter being felt exposed at the bottom of the ab- scess. During the following month the inflammation excited by the operation continued, and several abscesses presented themselves in the neighborhood of the first. These, however, all healed favorably without any exfoliation of bone taking place. The cavity made by the trephine became filled up by granulations, and the Avound gradually cicatrised. From the time of the ope- ration, the peculiar pain, from which "the patient had previously suffered, Avas entirely relieved; and it was not long before he was quite restored to health, and able to walk and pursue his occupations Avithout interruption. When I last saw him, nearly two years from the time of the operation having been performed, he continued Avell. 3. Absorption of the articular cartilages, to a limited extent, sometimes takes place, by a process apparently different from that of ulceration. The bone becomes partially denuded, but it bears no marks of inflammation ; there is no erosion of the bony surface itself; and the cartilage, Avhich re- mains entire, retains its natural adhesion to it. The patient does not com- plain of pain in the joint, nor does suppuration folloAv. These changes are observed more frequently in the bodies of elderly persons; and they are sometimes discovered after death, where their existence had not been sus- pected during the patient's life time. At other times, they produce in the mo- tions of the limb a grating;, corresponding to, but less distinct than the grat- ing Avhich is perceptible after a fracture. 4. There is a class of cases, of no unfrequent occurrence, in which the patient suffers considerable distress, in consequence of pain referred to some of the larger articulations, and which often occasion no small degree of anx- iety and alarm among the patient's friends, although there never arise any ul- timate bad consequences. The cases to Avhich I allude occur chiefly among hysterical females. The disease appears to depend on a morbid condition of the nerves, and may be regarded as a local hysterical affection. At first there is pain referred to the hip or knee, or some other joint, without any evi- dent tumefaction ; the pain soon becomes very severe, and, by degrees a puffy SAvelling takes place, in consequence of some degree of serious effu- sion into the cells of the cellular texture. The swelling is diffused, and, in most instances, trifling; but it varies in degree: and I have knoAvn, Avhere the pain has been referred to the hip, the Avhole of the limb to be visibly en- larged from the crista of the ilium to the knee. There is always exceeding tenderness ; connected Avith which, however, Ave may observe this remarka- 116 OBSERVATIONS ON THE ble circumstance, that gently touching or pinching the integuments, in such k a Avay as that the pressure cannot affect the deep-seated parts, Avill often be productive of much more pain than the handling of the limb in a more rude and careless manner. In one instance, Avhere there Avas this nervous affec- tion of the knee, immediately below the joint there Avas an actual loss of the natural sensibility; the numbness occupying the space of about tAvo or three inches in the middle of the leg. Persons Avho labor under this disease are generally liable to other hysterical complaints; and, in all cases, the symp- toms appear to be kept up and aggravated by being made the subject of con- stant attention and anxiety. No general rules can be laid down for the treatment of cases of this de- scription. The patient sometimes, Avhen the pain is most severe, derives benefit from the use of the following embrocation, applied tepid:— #. Spiritus Rosmarini, %iss. Misturae Camphorae, gviss. M. Fiat Embrocatio. Or the folloAving liniment:— #. Linimenti Camphorae Compositi %'iv. Extracti Belladonnae, 3ij. Fiat Linimentum. Sometimes the symptoms have abated under the use of active purgatives; or of valerian combined Avith bark or ammonia; or of injections of assafoe- tida. Where the menstruation is irregular, we may suppose it to be of the first importance that we should endeavor to restore this function to its healthy condition ; and if it be deficient, steel may be exhibited Avith advantage ; or if it be excessive, the mineral acids, combined Avith sulphate of magnesia, may be administered instead. In a great number of cases, in Avhich the symp- toms, Avhich have been just described, exist in combination Avith a feeble circulation, cold hands and feet, and almost complete Avant of appetite, the folloAving combination of medicines will be found to be very useful:— #. Infusi. Quassiae, gss. Tinctures ferri ammoniati, gss. Ammonias carbonatis, gr. A'j. Syrupi aurantii, sy. Aquae destillatae, gvij. Fiat haustus bis vel ter quotidie sumendus. But none of these remedies will do for the patient what may be accom- plished by other means. Her attention should be as much as possible Avith- draAvn from the subject of her complaints, and directed to other objects. She should be encouraged to take exercise out of doors, especially on horse- back; to rise early, so that only a moderate number of hours may be passed in bed ; to live in a cheerful society, and if she has* abandoned them (which has too frequently happened,) to resume, in all respects, the habits of a healthy person. In general, it is not difficult to distinguish the cases Avhich I have just described from those of more serious disease. Careless surgeons, however, frequently fail in their diagnosis ; and even surgeons of experience do so in DISEASES OF THE JOINTS. 117 some instances. I do not hesitate to say, that a large proportion of young ladies, who have heretofore been supposed to labor under disease of the hip- joint, and the great majority of those who have been treated as suffering from caries of the spine, have, in reality, been affected Avith these local hysterical symptoms, and nothing more. Except where there is a question concerning life and death, no error in surgical practice can be more dangerous than this ; as it may lead to a patient being confined to her couch, almost in soli- tude, for months, or even for years, Avho ought to be taking exercise, and breathing the fresh air, and partaking of the amusements, and enjoying the society of those of her own age. 5. We have abundant opportunities of observing that the joints of differ- ent individuals are endowed with different degrees of mobility. This is often very evident in the articulations of the fingers with the metacarpal bones. We see one person whose fingers admit of being extended so as to be in a line with the bones by which they are supported, but of no further motion in this direction ; and we see another, in whom they are capable of being bent backwards, so that the nails may be brought almost in contact Avith the back of the hand. I suppose that this difference is to be attributed chiefly to the state of the ligaments, by which the bones are held together ; and a corresponding looseness of the ligaments, but existing to a still greater extent, will explain the singular liability to dislocation which may be ob- served in some individuals. A gentleman consulted me in the year 1820, who had met with the accident of dislocating the patella four times in the right, and once in the left knee. The right shoulder had been twice com- pletely dislocated, and once there had been a subluxation of the same joint. The joint of the left thumb, Avith the os trapezium, had been dislocated seve- ral times. In every instance the dislocation had been reduced Avith the greatest facility, and generally Avithout surgical assistance. The patient, at the time of ray seeing him, was not more than twenty-three or twenty-four years of age, and was in perfect health j except that he was subject to occa- sional severe headaches, apparently connected with the state of his digestive organs. No peculiarity could be observed in the form and structure of his joints. His muscles were strong, and he was capable of considerable mus- cular exertion ; he was accustomed to a good deal of walking exercise, but had not been particularly exposed to the ordinary mechanical causes of dis- location. Case LXXVII.—6. A lady, in the year 1808, first observed a swelling in the upper part of one knee, which was unattended by pain, and which in- creased slowly, but uniformly. In the course of three years it had attained so inconvenient a magnitude, that she was induced to consent to the removal of the limb. Mr. Thomas, under whose care the patient was, performed the operation, and allowed me afterAvards to examine the amputated joint. The tumor occupied the upper part of the knee, beginning at the edge of the cartilaginous surface, and extending about three or four inches up the loAver part of the thigh. It was interposed between the muscles and the bone of the thigh, so that the former Avere seen expanded over it. It was of a greyish-white color; composed of fibres of a gristly semi-transparent sub- stance, Avith osseous matter intermixed Avith it, and about tAvo inches in thick- ness on each side of the femur. At the upper part it was seen distinctly originating in the periosteum; at the loAver part, the periosteum could not be traced, and the structure of the bone Avas continued into that of the tumor. The cartilages and ligaments of the joint were free from disease. On the ex- ternal surface of the synovial membrane unconnected Avith the diseased struc- 118 OBSERVATIONS ON THE ture above, there Avere three or four flattened bodies ; each of about the size of a kidney bean, of a white color, and of a texture somewhat softer than that of cartilage. The synovial membrane itself was free from disease. There can be no doubt that, in this case, the original disease was the osteo- sarcomatous tumor, originating in the periosteum of the femur. The circum- stance of the other tumors being found connected with the synovial mem- brane, although the intermediate parts were, to all appearance, in a healthy state, is remarkable; but something corresponding to this may be observed in other diseases. For example, Avhen the gland of the breast is affected with scirrhus, it is not unusual to find small tubercles of a similar structure in the skin near it, at various distances from each other, although the intermediate adipose substance, as Avell as the portions of skin between the tubercles them- selves, exhibit no marks of disease. I met with another case, in Avhich the patient appeared to labor under an enormous tumor of the hip. It Avas ascertained, by dissection, that the hip itself Avas free from disease, and that the enlargement was formed by an osteo-sarcomatous growth from the periosteum of the upper extremity of the femur. Tavo other cases have come under my observation, apparently simi- lar to that just mentioned, but in which I had not the opportunity of examin- ing the parts by dissection. 7. The following remarkable case seems worthy of being recorded, as it is one of those which might, by a superficial observer, be mistaken for caries of spine. It confirms a remark Avhich I have made formerly, namely, that disease affecting the cervical portion of the spinal chord produces para- lysis of the upper extremities, in the first instance, and of the lower extre- mities aftenvards. Case LXXVIII.—A young man, about tAventy-one years of age, in January, 1829, after leading a very irregular life, and especially after having been much exposed to damp and cold, was seized with a violent pain in the neck, followed by considerable swelling. The swelling Avas situated chiefly on the right side, extending from the head to the shoulder. The patient paid little attention to his complaints ; living as usual Avith respect to both diet and exer- cise ; but, in spite of this neglect, in a short time the pain and swelling, in a great degree, but never wholly, subsided. In the beginning of the following April, the upper extremity of the right side became affected Avith paralysis. AfterAvards the opposite limb became, to a great extent, paralytic also. In this state he remained, no active remedies having been adopted for his relief, until he came under my care in the be- ginning of June. At this time he complained of some degree of pain in the back of the head and neck ; and he found it difficult to move the head from one side to the other. An enlargement and induration of the soft parts of the neck was still perceptible in the situation of the original swelling. There Avas complete paralysis of the muscles of the right arm, forearm, and hand : those of the opposite limb were also paralytic, but some of them were still capable of act- ing feebly, so that he could take hold of the right hand with the left, and move it from one position to another. The muscles of the lower limbs were feeble, but Avere capable, nevertheless, of supporting the body in the erect posture. The bowels were very torpid, and the evacuation of a dark color, a good deal resembling tar in appearance. The urine was slightly alkaline, but voided Avithout difficulty. Leeches Avere applied to the neck, and afterwards a seton was introduced. DISEASES OF THE JOINTS. 119 Mercury was given so as slightly to affect the gums. No amendment, how- ever, followed the use of these remedies. The lower limbs became paralytic and on the 19th of June the patient died, having been for a short time pre- viously in a state of coma. On examining the body after death, the ventricles of the brain were found to contain about two ounces of watery fluid. The brain itself Avas of an unusually soft consistence. The cervical portion of the spinal chord was also softer than natural. A quantity of soft solid substance, of a grey color, apparently lymph, which had become organized, Avas found situated between the dura mater and the bodies of the vertebrae, occupying the whole of the anterior and some of the posterior part of the vertebral canal, and extending from the occiput doAvn- >vards, as low as the fourth cervical vertebra. A substance similar to that which was found on the inside of the vertebral canal was also found lying on the fore part of the bodies of the cervical ver- tebrae, extending over the oblique and transverse processes, and communica- ting with the internal mass by processes extending through the spaces in Avhich the nerves are situated, and surrounding the nerves themselves. The external mass Avas much larger than the internal, being not only thicker, but extending lower down in the neck. In some parts it Avas not less than an inch in thickness : in other parts thinner, and, altogether, it was of a very irregular shape. 8. The effects of gout on the joints are very remarkable. The cartilages are absorbed; the exposed surfaces of bone are partially, or entirely, encrusted with a white earthy matter, which I conclude to be lithate of soda; and sometimes they have the appearance of being formed into grooves, as if they had been worn by their friction on each other. In some cases, repeated and long-continued attacks of gout occasion complete anchylosis. 9. Mr. Mayo has published a history of some cases, in which ulceration of the articular cartilages took place under peculiar circumstances, having the character of being an acute disease instead of a chronic affection, as in other instances. Since Mr. Mayo's paper on this subject was published in the Medico-Chirurgical Transactions, some cases apparently of the same kind have fallen under my own observation. They are recorded in a former part of this volume. 10. I may take this opportunity of noticing a circumstance, which is of some importance as connected with the diagnosis of disease in the hip-joint. It occasionally happens that the tAvo lower extremities are not of precisely the same length ; and this may be the result of original formation, the femur and tibia of one side being respectively longer than those of the other side. If the whole of this difference amounts, as it sometimes does, to an inch, or an inch and a half, the individual is observed to limp in Avalking, and the great trochanter belonging to the longer limb is higher and more prominent than that of the other ; and this might lead a superficial observer to mistake the case for one of diseased hip. In some instances, there is a difference in the length of the two lower limbs, in consequence of disease. A diseased bone for the most part does not keep pace m its growth with the other parts of the body; but I have known the reverse of this to happen, of which the following is a remarkable instiincG * i Case LXXIX.—Master M. Avas brought to me for my opinion, '^June, 1832. I saw him in consultation with Dr. Lefevre, physician to the British embassy at St Petersburgh. 120 OBSERVATIONS ON THE The cicatrices of three or four abscesses were seen in the skin on the ante- rior and upper part of the thigh, and there was considerable thickening of the deep seated soft parts in the same situation, there being also a manifest adhe- sion of them to the bone. The appearance of the limb was such as would lead to the belief that there was a portion of diseased or dead bone of the femur, Avith probably some new bone formed round it; and that this had produced a succession of abscesses of the soft parts, as in ordinary cases of necrosis. The history of the case seemed to justify this opinion as to the nature of the disease. Three years and a half ago the little boy had been suddenly seized Avith severe pain, which Avas referred to the knee, but only for a few hours, at the end of which time it shifted its place to the upper and anterior part of the thigh. The pain continued, and swelling immediately took place. At the end of six months an abscess was opened, Avhich, however, soon healed. Afterwards a second abscess formed, Avhich Avas folloAved by others; but all of them had healed without any exfoliation having hitherto taken place. There Avas some degree of stiffness of the hip-joint, but no more than might be reasonably attributed to the thickening and swelling of the soft parts in the neighborhood. But the most remarkable circumstance in the case was, that the diseased thigh-bone, when measured from the anterior spinous process of the ilium to the patella, Avas found to be at least an inch and a quarter longer than that of the sound limb. The measurement was made repeatedly and Avith the greatest care, so that there could be no mistake respecting it. There Avas no perceptible difference in the length of the bones of the tAvo legs. In consequence of one limb being thus longer than the other, when the pa- tient stood erect, Avith the soles of his feet planted on the ground, the great trochanter on the side of the disease appeared to projeet unnaturally, and this occasioned a manifest alteration in the form of the nates, someAvhat corres- ponding to what is observed in the less advanced stage of disease of the hip- joint. That this appearance of the nates was to be attributed solely to the difference in the length of the two limbs, was proved by this circumstance, that it Avas at once removed by placing a book an inch and a quarter in thick- ness under the foot of the sound limb, so as to raise that side of the pelvis to the same level Avith the other. DISEASES OF THE JOINTS. 121 CHAPTER X. ON INFLAMMATION OF THE BURS^E MUCOSAE.* History and Symptoms of this Disease. Inflammation of the bursae mucosas is marked by nearly the same charac- ters, and (allowance being made for the difference of the parts with which they are connected) produces nearly the same results as inflammation of the synovial membranes of the joints. In the greater number of instances, it occasions an increased secretion of synovia. In other cases, the bursa is dis- tended by a somewhat turbid serum, with portions of coagulated lymph float- ing in it. Occasionally it terminates in the formation of abscess. Sometimes the membrane of the bursa becomes thickened, and converted into a gristly substance. I have seen it at least half an inch in thickness, with a small cel- lular cavity in the centre containing synovia. At other times, although the inflammation has continued for a very long period, the membrane of the bursa retains nearly its original structure. Inflammation of the bursae mucosae may be the consequence of pressure or of other local injury. It may arise from the too great use of mercury, from rheumatism, or from some other constitutional affection; and, in such cases, it is frequently combined with inflammation of the synovial mem- branes of the joints. Sometimes it has the form of an acute, but more fre- quently it has that of a chronic inflammation. The inflamed bursa forms a tumor, more or less distinct, according to its situation ; more or less painful, according to the character of the inflamma- tion. If the bursa be superficial, the fluctuation of fluid within it is, in the first instance, very perceptible: and, under these circumstances, if the inflammation be considerable, it extends to the surrounding parts, and occa- sions a redness of the skin. When the disease has existed for a certain pe- riod of time, it generally happens, that the fluid is less distinctly to be felt on account of the membrane having become thickened; and, occasionally, this takes place to such an extent, that the tumor exhibits all the characters of a hard solid substance, of which the fluid contents are imperceptible. When the inflammation is of long standing, it is not unusual to find float- ing in the fluid of the bursa a number of loose bodies, of a flattened oval form, of a light-brown color, with smooth surfaces, resembling small melon seeds in appearance. There seems to be no doubt that these loose bodies * I include under this head the membranes forming the sheaths of tendons, which have the same structure, answer a similar purpose, and ^^t^\V^P^^^«^^^ other bursae. I adopt the term bursa mucosa, because it has been in general use, although it ill expresses the functions of the organs to which it is applied. 16 122 OBSERVATIONS ON THE have their origin in the coagulated lymph which was effused in the early stage of the disease: and 1 have had opportunities, by the examination of several cases, to trace the steps of their gradual formation. At first the coagulated lymph forms irregular masses of no determined shape, Avhich afterwards, by trie motion and pressure of the contiguous parts, are broken down into smaller portions. These, by degrees, become of a regular form, and assume a firmer consistence: and at last they terminate in the flat oval bodies, which have been just described. When inflammation of a bursa mucosa ends in suppuration, the abscess sometimes makes its way directly to the surface of the skin, and bursts ex- ternally: but I suspect that, in other cases, the matter, in the first instance, escapes into the surrounding cellular membrane, and then it is liable to be confounded with those abscesses which originate in this texture. The fol- lowing circumstances seem to warrant this opinion. There is no bursa more liable to be inflamed than that between the patella and the skin ; and inflam- mation of it not unfrequently terminates in suppuration, as I have ascer- tained to be the case, both by the discharge of pus, when the tumor has been punctured, and by dissection after death. It is very common to find a large abscess on the anterior part of the knee, Avhich the patient describes as hav- ing commenced over the centre of the patella in the situation of this bursa. The abscess has a somewhat peculiar character. It raises the skin from the patella, so that the latter cannot be felt, and from this point, as from a cen- tre, it extends itself betAveen the skin and the fascia, equally in every direc- tion, covering the whole of the anterior part of the knee. A superficial ob- server, judging from the general form of the tumor, and the fluctuation of fluid, without noticing the greater redness of the skin, and the circumstance of the fluid being over, instead of under the patella, might mistake the case for one of inflammation of the synovial membrane of the joint itself. Such an abscess must be supposed to commence either in the bursa above mention- ed, or in the cellular texture. The original situation of the disease corres- ponds to that of the bursa: there appears to be no reason Avhy an abscess of the cellular texture should occur in this precise spot, more frequently than elsewhere ; and hence, it is reasonable to conclude, that the bursa is the part in which the abscess begins. It is not improbable that many other abscesses of the extremities may have a similar origin. The tumor Avhich occurs in the inside of the ball of the great toe, and Avhich is one of those to which the name of bunion has been applied, occasionally suppurates; and I have found, on dissection, that this is formed by an inflammation of the bursa, which is here situated. It frequently happens, after the inflammation has entirely subsided, that the disposition to secrete a preternatural quantity of fluid still remains, and that a dropsy of the bursa is the consequence ; in like manner as hydrocele takes place, in some cases, as a consequence of inflammation of the tunica vaginalis of the testicle. Such tumors are very commonly met Avith in the neighborhood of the wrist, and are sometimes confounded with ganglions. The enlarged bursa on the anterior part of the Avrist has somewhat peculiar characters: it is bound down in the centre by the strong annular ligament, which binds down the flexor tendons; and it is prominent above and below, where the superjacent parts afford a smaller degree of resistance. Pressure made on the upper part of the tumor causes the fluid to pass altogether into the palm of the hand, and, in like manner, pressure on the loAver part of it causes it to ascend into the forearm. DISEASES OF THE JOINTS, 123 SECTION II. On the Treatment. In the first instance, leeches and cold lotions, and afterwards blisters, or stimulating liniments, may be employed with advantage ; and in particular cases these may be combined with the use of the Colchicum, or such constitu- tional remedies as their peculiar circumstances seem to indicate. Under this treatment the inflammation of the bursa may be relieved without difficulty; and, in the early stage of the disease, the fluid which has been effused will become absorbed. But where the disease has been long established, the preternatural secre- tion of fluid will often continue after the inflammation has entirely subsided. Under these circumstances, a blister may be applied, and kept open with the savine cerate, the part being at the same time supported by a splint or ban- dages, so as to limit its motion, or rather, so as to keep it in a state of abso- lute immobility. In many cases, the loose bodies, which have been described in the last section, are found in the cavity of the bursa; and these may in in themselves be sufficient to keep up the formation of fluid. Under these circumstances, the first step towards a cure is to puncture the bursa, so as to allow these loose bodies to escape. I have observed, where the puncture of the tumor is followed by suppura- tion, and the whole cavity of the bursa is thus converted into an abscess, that, after the suppuration has ceased, no further collection of fluid, in general, takes place, so that there is a permanent cure of the disease. Hence I have sometimes been induced after using the lancet, to bring on suppuration by ar- tificial means. This may be effected by introducing a seton or tent into the wound, or by making a free opening into the bursa, and dressing the cavity of it with lint. Even where the bursa forms the sheath of one or more ten- dons, this method may be employed with safety; provided that the bursa has no communication with the cavity of the neighboring joint. We must, however, proceed with caution where the bursa is dilated to a considerable size. Inflammation and suppuration of a large bursa sometimes disturbs the constitution in so great a degree, that it may be doubtful whether it would be prudent, in this instance, to do more than simply puncture the tumor, keeping the patient in a state of perfect quietude afterwards. A large swelling, formed by a cyst distended Avith serum only, or with serum and masses of coagulated lymph floating in it, occasionally is met with over the inferior angle of the scapula ; originating either in the large bursa mucosa, which is interposed at this part between the scapula and the latissimus dorsi muscle, or otherwise in one of the bursas of the shoulder, protruding from un- derneath the muscles, by which that joint is surrounded. I had an opportunity of seeing a tumor of this description, which had attained a magnitude not much less than that of a man's head. I understood that the cyst was after- wards punctured, and a seton passed through its cavity, and that so much dis- turbance of the general system ensued, as to occasion death. I have seen another case, in which death took place in a short time after such a tumor was punctured: but here the patient Avas otherwise in bad health, and that 124 OBSERVATIONS ON THE strict attention was not paid to his being kept in a state of quietude after the operation, which circumstances seem tohave required. I shall give an ac- count of a more fortunate case of the same kind hereafter. When the coats of the bursa have become much thickened, I am not aware that there is any method, by which they can be restored to their natural con- dition. If the diseased bursa be situated superficially, it may be removed with as much facility as an encysted tumor. I have never, indeed, per- formed this operation myself, nor have I heard of it being done by others, except on the bursa, which is situated between the patella and the skin ; but there can be no doubt that there are some other superficial bursae to Avhich the • operation would be equally applicable if occasion called for it. On the other hand, where the bursa envelopes tendons, or where it is deep-seated, the operation must be impracticable; and where the bursa communicates with the cavity of a joint, if practicable, it must be improper. In those cases, where the bursa over the patella has been extirpated, I do not know that the patient has afterwards suffered any inconvenience from the want of it; and, in fact, there is sufficient evidence that a new bursa is ulti- mately formed in the place of that which had been taken away. A synovial membrane is of simple structure. It may be resolved by maceration into cellular texture; and instances are not wanting of new synovial membranes being formed where none before existed. Such is the case in an artificial joint after an ununited fracture. In a young lady, Avho had attained the age of ten or twelve years, laboring under the inconvenience of a club foot, a large bursa was distinctly to be felt on that part of the instep which came in con- tact with the ground in walking; and in another young lady, Avho had appa- rently recovered of a caries of the spine, attended with a considerable angular curvature, a bursa appeared to have been formed between the projecting spinous process and the skin. SECTION III. Cases of this Disease. Case LXXX.—Mary Newnham, twenty-tAvo years of age, was admitted into St. George's Hospital, having the bursa over the right patella enlarged to the size of a small orange. It contained fluid, and the membrane of the bursa appeared to be very little thickened. At this time she experienced no pain, and there was no inconvenience, except what arose from the bulk of the tumor. Blisters having been applied, and other methods having been applied, with a view to promote the absorption of fluid, without success, I made a puncture with a lancet, and more than an ounce of serous fluid escaped. I then intro- duced the blunt end of a probe and irritated the inner surface of the bursa; in consequence of which, on the following day, there Avas some degree of pain and swelling, with a slight symptomatic fever. On the fourth day after the operation, on removing the dressings, about half an ounce of pus was dis- charged. The suppuration continued, but the quantity of pus daily dimin- ished, and, at the end of three weeks, the wound Avas healed, and the tumor had wholly disappeared. Case LXXXI.—Mrs. T., between tAventy and thirty years of age, in the middle of March, 1818, first observed a tumor situated over the inferior & DISEASES OF THE JOINTS. 125 angle of one scapula, and attended with a trifling degree of pain and tender- ness. In the course of a week, the tumor had attained its greatest magnitude, and then remained stationary. In the following April, when she came under my care, the tumor Avas of the size of a large cocoa-nut; of an oval shape ; distinctly circumscribed; occupying the place of the large bursa mucosa, which is situated between the latissimus dorsi muscle and the inferior angle of the scapula. On the 22d of May, the tumor being nearly in the same condition, I made a puncture with an abscess lancet, and about a pint of turbid serum Avas evacuated, with some irregularly shaped masses of coagulated lymph floating in it. Adhesive plaster Avas placed over the wound, and secured by a com- press and bandage; and she was desired to remain perfectly quiet in bed. The wound did not heal by the*first intention ; and, on removing the dressing. at the end of four days, a considerable quantity of pus escaped. The dis- charge of pus continued, but the quantity daily diminished; no untoward symptoms took place, but nearly three months elapsed before the suppuration had entirely ceased, and the wound had healed. At this time there Avere no remains of the tumor, and she was in all respects well. Case LXXXII.—A. B., a middle-aged woman, became a patient of St. George's Hospital, under Mr. R. Keate, on account of a tumor on the back art of the wrist, of the size of a double walnut, containing fluid ; and Avhich ad been the consequence of inflammation of the bursa mucosa, which en- velopes the extensor tendons of the fingers. At the time of her coming to the hospital the inflammation had entirely subsided, and the tumor occasioned no inconvenience, except what might be attributed to its bulk. After having employed various local remedies without any reduction of the swelling, a puncture was made, and a considerable quantity of serous fluid was evacu- ated. In a short time, however, the fluid was again collected in as large a quantity as before. Afterwards Mr. R. Keate made a longitudinal incision in the skin over the tumor, and dissected out as much as possible of the bursa, leaving only that part of it which enveloped the tendons. The Avound sup- purated, and healed gradually ; and, at first, it was supposed that the opera- tion had produced a cure. But in a few weeks after the Avoundhad cicatrised, the tumor reappeared, having the same character as before, but being of not more than one half of its former size: and when I last saw the patient it continued in the same state. Case LXXXIII.—Ruth Target was admitted into St. George's Hospital, in August, 1809, on account of a hard and apparently solid tumor, of the size of a small orange, situated between the patella and the skin, and perfectly movable on the parts below. Having made a longitudinal incision of the integuments, I removed the tumor with perfect facility. A slight degree of symptomatic fever followed the operation, which, however, speedily subsided, and, at the end of a month she was discharged as cured, suffering no inconvenience except a very trifling sense of stiffness when she walked. On examining the tumor, after its removal, it Avas found to be formed by the bursa, which is situated over the patella; the parietes of which had be- come more than half an inch in thickness, and of a ligamentous texture; while the interior retained its natural cellular structure, and Avas filled Avith a serous fluid. I have since performed a similar operation on several patients. In each case, after the Avound Avas healed, there Avas at first considerable stiffness of the knee, in consequence of the cicatrix having formed a close attachment I ** 126 OBSERVATIONS ON THE to the anterior surface of the patella. Where, however, I had the opportu- nity of seeing the patient afterwards, I always found that this inconvenience had been of short duration, and that there Avas every reason to believe that the bursa had been regenerated. The following case is not without interest, proving as it does, beyond the possibility of doubt, that such regeneration ac- tually takes place. Case LXXXIV.—Mary Buckly, seventeen years of age, was a patient in St. George's Hospital, in the beginning of the year 1828, on account of a tumor formed by an enlargement of the bursa between the patella and the skin. The tumor was removed entire by the late Mr. Rose. About the beginning of November, 1828, another tumor presented itself in the situation of that which had been taken aAvay. This tumor gradually increased in size; and, when she was readmitted into the hospital on the 14th of January, 1829, it had all the character of an enlarged bursa, occu- pying the exact place of that which had existed formerly. January 21st. I made a free incision into the tumor with a lancet There was a cavity in its centre, from which lymph and serum escaped :the surface of it thus exposed was dressed with dry lint and a poultice over it. It soon became covered with granulations ; and on the 4th of February the patient left the hospital cured. ADDITIONAL NOTES. 1. On Ulceration of the Articular Cartilages. Among the cases which have been recorded in the foregoing pages, there are several in which the cartilages of a joint Avere found to have been ab- sorbed on the surface towards the articular cavity; Avhile the larger, next the bone, retained its natural adhesion, and was in other respects unaltered. I have always regarded this partial removal of the cartilage as not to be ex- plained, except on the supposition of its having been acted on by its own vessels. And, in the beginning of the fourth chapter, I have given my rea- sons for believing that this circumstance is by no means remarkable, or con- trary to what might, a priori, have been expected. My friend Mr. Key, in an interesting paper, which he has lately published in the Medico-Chirurgical Transactions, has related the history of a case, in which a similar appearance%f the cartilage was connected Avith an inflamed state of the synovial membrane, processes or elongations of which were seen lying in contact with the articulating surfaces: and from this and some other circumstances, he has been led to infer, that this kind of absorption of the cartilage is to be attributed, not to any changes originating in the cartilage itself, but to the action of the vessels ef the synovial membrane; and, fur- ther, that Avhen inflammation of the last mentioned structure is folloAved by ulceration of the cartilage, the ulceration is accomplished in the same man- ner ; the vessels of the cartilage being, in fact, unequal to such a process of destruction. I have had no opportunity of examining the preparation from which the drawing annexed to Mr. Key's paper has been taken ; and I cannot, therefore, venture to contradict the opinion which he has expressed respecting this par- ticular case. If it be correct, it establishes a new fact in pathology; as I am pot aware that there is any instance, in other parts of the body, oi the ulcer- DISEASES OF THE JOINTS. 127 ation or absorption of one living texture being affected by the action of the vessels of another, there being no continuity of substance between them. The perusal of Mr. Key's paper has, however, induced me to renew my inquiries on the subject; and, in doing so, I have found Avhat appears to me to be abundant and satisfactory evidence that the explanation, which he has offered, does not admit of a general application, and that the absorption of the cartilage, commencing on the surface towards the cavity of a joint, may take place under such circumstances, that it cannot be supposed to be the result of any other agency than that of the vessels of the cartilage itself. The folloAving facts are only a part of those which might be adduced, if it were necessary in confirmation of what has been just stated. 1. At page 36 of this volume, I have mentioned the case of a boy in whom this partial absortion of the cartilage of the knee had taken place. In some parts the cartilage had altogether disappeared; in other parts, it had been absorbed on the surface towards the cavity of the joint, while the layer next the bone, remained entire; thus presenting the appearance of grooves, as if a portion of its substance had been removed by a chisel. Now according to Mr. Key's hypothesis, the absortion of the cartilage, in this case, ought to have been produced by villous processes of the synovial membrane projec- ting into the cavity of the joint, and lying in contact with the articulating surfaces. But no such villous processes existed, nor is any thing said in my manuscript notes of the synovial membrane having been even inflamed. In- deed, if it were inflamed at all, it must have been so only to a very small extent, as it is expressly stated, that there was no effusion, either of pus or synovia, into the cavity of the joint. It is to be presumed that, if the ab- sorption of the cartilage had been effected through the agency of the synovial membrane, it would have begun, and would have made the greatest progress, at the part most exposed to contact with it, namely, at the margin ; and this corresponds with Mr. Key's OAvn observations on the subject. But, in exa- mining the condyles of the femur taken from this patient, which are preserved in spirits in the museum of St. George's Hospital, I find that this is exactly contrary to what has really happened. Throughout nearly the whole of its circumference, for the breadth of one third of an inch, the cartilage remains of its natural thickness, and otherwise unaltered; in the centre of the bone it has altogether disappeared, and the grooved appearance of it is observable in the intermediate space.* 2. In the case of Harper, related at page 40, the cartilage covering the head of the femur had been destroyed by ulceration for more than half its extent so as to expose the cancellous structure of bone. The remaining portion of the cartilage was thinner than natural; but this was more observable in some parts than in others. With the exception of one spot of limited extent, this partial loss of substance had taken place towards the cavity of the joint, the layer of cartilage next the bone being unaltered. The synovial membrane was somewhat more vascular than usual; but the increased vascularity seemed scarcely to amount to inflammation. 3. I have in my possession a drawing made from a knee, amputated within the last six or seven years in St. George's Hospital, in which the same par- * It is worthy of notice, that in this case there was a large abscess of the thigh, external to the knee-joint. A similar abscess existed in one of the cases described by Mr. Mayo in the Medico-Chirurgical Transactions, to which I shall have occasion to refer presently. Three other cases have fallen under my observation, in which a large abscess, external to a joint, was accompanied with ulceration of the articular cartilages; no suppuration having taken place in the joint itself. 128 OBSERVATIONS ON THE tial absoqition of the cartilage covering the head of the tibia and condyles of the femur had taken place, producing the appearance of grooves on the sur- face toAvards the cavity of the joint. In this case there are manifest indica- tions of the same process having begun in the cartilage of the patella, and of that portion of the femur with which the patella was in contact, and to which the A'illous processes of the synovial membrane (of which there are no indications in the draAving,) even if they had existed, could not easily have penetrated. The condyles of the femur belonging to this case are preserved in the museum of St. George's Hospital; and, on examining them, I find that the absorption of the cartilage had been almost wholly confined to the centre of the bone; while at the margin, where it must have been the most exposed to being acted on by the synovial membrane, scarcely any absorption of it had taken place. 4. In a paper on the ulceration of the cartilages of the joints, published by Mr. Mayo in the 11th volume of the Medico-Chirurgical Transactions, a case is described, in Avhich, on exposing the cavity of the joint, in dissection, " the surfaces of the astragalus, tibia, and fibula Avere found almost wholly stripped of their cartilage: Avhat remained of this texture Avas thinned, and that unequally, but seemed in other respects unchanged, and adhered firmly to the bone. The same alteration was observed in the other joints, Avhich the astragalus concurs in forming. The exposed surfaces of bone were healthy." In answer to some inquiries Avhich I have lately made, Mr. Mayo has informed me, that " the synovial membrane Avas red and thickened where it lined the capsular ligament; but there were none of those villous processes projecting into the cavity of the joint Avhich Mr. Key has described as the agents by which the absorption of the cartilages is effected." Indeed, Avho- ever*considers the peculiar form and relative position of the articulating sur- faces of the ankle-joint, Avill, I conceive, find it difficult to understand hoAv those processes, even if they had existed, could have extended into the joint, so as to perform the office Avhich Mr. Key has assigned to them. If any fur- ther proof be required of the synovial membrane not having been concerned in the absorption of the cartilage, in this particular instance, it is afforded by the preparation of the astragalus which is preserved in the museum of King's College, and Avhich Mr. Mayo has allowed me to examine. In the central part of each articulating surface the cartilage has become absorbed to a great extent, and what remains is reduced to a very thin layer, adhering as firmly as usual to the bone ; but at the margin, close to the reflection ot the synovial membrane over it, a narrow strip of cartilage is almost every where perceptible; and iMmany places there are portions of cartilage, of their ordinary thickness, and evid ently not altered from their natural condition. In speaking of ulceration of the articular cartilages as a consequence of inflammation of the synovial membrane, I have not endeavored to explain the exact nature of the process by which such ulceration is effected, and simply for this reason,—that I have not been able completely to satisfy my own mind on the subject. There can be no doubt that, in many instances, ulceration begins at the margin of the cartilage, Avhere the synovial membrane is reflected over it from the neighboring bone, or from the interarticular ligaments, where such ligaments exist; but it may still admit of a question, in what manner the ulceration is accomplished : whether it be from the inflammation extending directly to the cartilage itself, or to the bone first, and the carti- lage afterwards j* or Avhether, according to the vieAvs entertained by Mr. * I am led to offer this as one of the explanations which might be given of ulceration of the cartilage, induced by inflammation of the synovial membrane, in consequence of what was DISEASES OF THE JOINTS. 129 Key, the latter, being altogether in a passive state, becomes absorbed by the action of the vessels of the fringed processes of the synovial membrane lying in contact with it. But there are other cases of inflammation of the synovial membrane, in which ulceration begins in the centre of the cartilage; so that none of these hypotheses afford any reasonable explanation of it. It seems not improbable, that in some of those cases, which are usually regarded as examples of simple inflammation of the synovial membrane, the inflammation may not have been confined (even in the first instance) to this individual part, but may have begun simultaneously in all the textures of the joint This is in conformity with what is observed to happen occasionally in the eye, and in other organs; and, under such circumstances, it is no more than might be expected, that, as the inflammation subsides, the cartilage should ulcerate either in the centre, or in some other part of its surface. Nor is this a merely speculative opinion : at least, I am much mistaken if it be viewed in that light by any one who, after having perused the history of the following case, considers Avhat would probably have happened if the patient had not died of another disease, before there was time for the disease in the joint to have run its course. A gentleman, about twenty-five years of age, had labored for several years under a disease of the brain, in consequence of which he had been in a state of complete helplessness and imbecility. In the summer of 1820, he became indisposed otherwise ; there was a cluster of enlarged glands in the left groin, and a purulent sediment was deposited by the urine. I was now desired to see him in consultation Avith Dr. Maton, who was his ordinary medical atten- dant. Soon afterwards, it was observed that there was a general tumefaction of the left thigh and nates, and the patient complained of pain in certain motions of the limb. Under the treatment employed, the tumefaction sub- sided ; but immediately afterwards a violent attack of diarrhoea took place; under which he sunk and died on the 29th of July. On examining the body, we discovered an abscess, which seemed to have had its origin in the cellular membrane of the pelvis, near the neck of the bladder, which had burst into the neighboring portion of the Urethra, and which had also extended upwards on the left side, so that it could be traced as high as the mass of enlarged glands in the groin. The whole of the muscles surrounding the left hip-joint were preternatu- rally soft and vascular, and so altered from their natural condition, that they could be lacerated by the slightest force. They also were to a considerable extent detached or separated from each other, apparently in consequence of a serous fluid which had been effused between them, but of which nearly the whole had become absorbed. The capsular ligament and synovial membrane of the joint were of a red color, and unusually vascular : and the cartilages covering the head of the femur, and lining the acetabulum, Avere also red, and of a soft consistence, giving to the fingers a sensation someAvhat resem- bling that which is produced by touching velvet. In the scrofulous disease of the joints, which is described in the fifth chap- ter, the first change commonly observed is that the cartilage adheres less firmly than is usual to the bone, so that it may be easily separated from it. This is folloAved by absorption of the cartilage, beginning on the surface observed in Case I. p. 4, in which the cartilage presented no appearance of disease, except that, " at the edge of one of the condyles of the femur, it adhered to the bone less firmly than usual." I have observed, in some other cases, but especially in those of the scrofulous dis- ease, which has its origin in the bones, that a similar adhesion of the cartilage to the bone is not unfrequently to be noticed where the former is about to ulcerate. 17 150 OBSERVATIONS ON THE towards the bone. Occasionally red spots are observed in the cartilage, Avhich might be supposed to indicate an increased vascularity preceding ulceration, and, in two cases (that of Scales, page 69, and King, page 70), vessels injected Avith red blood could be distinctly traced extending from the bone into the cartilages covering them. The degeneration of the cartilage into a fibrous structure is no uncommon circumstance ; and I suspect that it is one cause of the crackling of the joints Avhich is not uncommonly met Avith in persons somewhat advanced in life. I have no doubt that it often exists Avhere it is never folloAved by ulceration; but I am also Avell assured that, in many other instances, it precedes, and in fact, forms, the first stage of this disease ; and several cases, confirming this observation, are recorded in former parts of the present volume. There are other cases, in Avhich Avhat I have described as primary ulcera- tion of the cartilage is preceded, not by this peculiar change of structure, put by a chronic inflammatory affection of the bone to which the cartilage is attached. I do not undertake to explain how these tAvo orders of cases are to be distinguished from each other in the living person : and, in fact, in the present state of pathological science, it is no more possible to do so, than it is to determine whether a node, formed by a thickening of the periosteum, has originated in the periosteum itself, or in the bone which it envelopes. Indeed, it is only during the very early stage of the disease that this distinc- tion can be made, even by the morbid anatomist; as, whatever may have been the state of the bone originally, its cancellous structure becomes affected Avith chronic inflammation as soon as ulceration originating in the cartilage has extended to it. Mr. Key has expressed some doubts Avhether, in the ordinary disease of the hip-joint, the cartilage is the part primarily affected ; and seems to regard it rather as the consequence of inflammation of the ligamentum teres. On this, as on other subjects connected Avith these inquiries, I do not undertake to do more than state the results of my own individual experience; and they are as follows:—During a series of years, I sought every opportunity of examining the morbid appearances of the hip-joint, more especially in the early stage of disease, Avhatever the disease might be ; and, in the cases Avhich came under my observation, I certainly found, in children under the age of puberty, that the scrofulous disease described in the fifth chapter predomi- nated, while, in adults, the disease, for the most part, manifestly began either in the cartilage itself, or in the surface of the bone beneath. In making this observation, of course I do not mean to contradict what I have formerly stated Avith respect to the occurrence of ulceration of the cartilages of the hip as a consequence of inflammation of the synovial membrane. Neither do I mean to assert, that there is no such thing as inflammation of the ligamentum teres preceding ulceration of the harder textures : but I am not aAvare that I have ever met with an instance of the kind ; nor is it what I should have much expected to be the case, considering how little liable the other articular ligaments appear to be to inflammatory affections.* * The view which 1 have taken of the more important diseases which occur in the hip- joint derives confirmation from what we see of those diseases of the joints between the bodies of the vertebra which terminate in caries cf the spine. We cannot overlook the correspond- ence between the diseases of the spine and those of the hip; nor how they occur under simi- lar circumstances, run nearly the same course, and seem tor the most part to depend on the same state of constitution. But the joints between the bodies of the vertebra* have no synovial membranes : and 1 do not know that there is the smallest evidence in lavor of the opinion, that the ligaments of the spine are ever the parts primarily affected. I have formerly stated "that an extensive car La of the spine may have its origin, sometim.a in an ulceration of tru* inter- DISEASES OF THE JOINTS. 131 Notwithstanding the ingenious arguments advanced by Mr. Key, I must acknowledge that I find no just grounds for the opinion, that the articular car- tilages are so little liable, as he supposes to be, to become ulcerated from the action of their own vessels. They may be regarded as bearing nearly the same relation to the synovial membrane which the transparent cornea bears to the tunica conjunctiva: yet hoAV rare is it to find ulcers of the last-men- tioned texture, and Iioav frequent are ulcers of the cornea ! I am not aware that there is any good reason to believe that the capability of ulceration is greater in those textures which possess much vascularity than it is in others. It is true, that tendons do not readily ulcerate ; but the same observation may be made with respect to the muscles to Avhich they are attached, although the latter receive a larger supply of blood, and, apparently, have their vital powers more developed than almost any other part of the animal system. The cicatrix of an ulcer, after a certain time, becomes less vascular than the skin by which it is surrounded ; yet, it is Avell known that the former is made to ulcerate from causes which would not produce ulceration in the latter; and this circumstance is, indeed, usually regarded as a proof of the cicatrix being endowed with inferior vital powers to those Avhich belong to parts of original formation. But setting these arguments aside, it may be observed that, although the articular cartilages, in the adult, at least, exhibit no vessels capable of carrying red blood, they must, nevertheless, be well supplied with the means of growth, and, probably, have greater power of reparation than any other textures in the body. None are exposed in the same degree to the influence of pressure and friction : which, hoAvever, produce no change in their condition. As long as they are thus exercised, they retain their natural thickness, and all their properties, unimpaired ; but Avhen these causes cease to operate, they Avaste like other organs, which are not kept in constant use, and in the course of time, may almost Avholly disappear. 2. On the Absorption of the articulating Cartilages complicated with the Effects of Friction on the Bones. The peculiar kind of absorption of the cartilages Avhich is described in page 119, as one of the effects of gout, occurs also in some of those cases of chronic rheumatic inflammation, which are often distinguished by the appellation of rheumatic goutj such as are described in the first chapter of this Avork, p. 11. The process by means of which this absorption is effected, is manifestly dif- ferent from ulceration, and is altogether very remarkable. The cartilages disappear, so that the bones are exposed ; but the latter present nothing cor- responding to the appearance of a carious surface. They bear evident marks of having been subjected to the influence of friction, but the consequence of friction on the living, are entirely different from those of friction on the dead bone. There is no exposure of the cancellous structure; a process of groAvth goes on simultaneously Avith that of destruction ; and the result is. the depo sit of a.hard and compact layer of bone over the cancellous structure, which would have been exposed otherwise. vertebral cartilages, and, at other times, in a morbid condition of the cancellous structure of the bodies of the vertebrae;" and whoever will be at the pains of seeking opportunities of stu- dying the pathology of caries of the spine by dissections made at an early period of the dia- pase, will, if I am not much mistaken, find abundant reason to confirm the truth of the above observation. THE END. * :'• NLM032776077